Chest pain
Chest pain usually results from disorders that affect thoracic or abdominal organs—the heart, pleurae, lungs, esophagus, rib cage, gallbladder, pancreas, or stomach. An important indicator of several acute and life-threatening cardiopulmonary and GI disorders, chest pain can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy.
Chest pain may arise suddenly or gradually, and its cause may be difficult to ascertain initially. The pain may radiate to the arms, neck, jaw, or back. It may be steady or intermittent and mild or acute, and it may range in character from a sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. Chest pain may be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.
Emergency interventions
Ask the patient when his chest pain began. Did it develop suddenly or gradually? Is it more severe or frequent now than when it first started? Does anything relieve the pain? Does anything aggravate it? Ask the patient about associated symptoms. Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a life-threatening disorder. (See Managing severe chest pain
, pages 162 and 163.)
History and physical examination
If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated findings, pages 164 to 167.)
Medical causes
Angina pectoris
A patient with angina pectoris may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound [S 4]) or a murmur during an anginal episode.
In Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by dyspnea, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.
Anthrax (inhalation)
This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial flulike signs and symptoms include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.
Anxiety
Acute anxiety—commonly known as panic attacks—can produce intermittent, sharp, stabbing pain, typically behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.
Aortic aneurysm (dissecting)
The chest pain associated with this life-threatening disorder usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.
Asthma
In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.
Blast lung injury
Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.
Blastomycosis
Besides pleuritic chest pain, this disorder initially produces signs and symptoms that mimic those of a viral upper respiratory tract infection: a dry, hacking, or productive cough (and sometimes hemoptysis), fever, chills, anorexia, weight loss, fatigue, night sweats, and malaise.
Bronchitis
In its acute form, this disorder produces burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm with increased coughing and wheezing.
Cardiomyopathy
In hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, a cough, dizziness, syncope, gallops, murmurs, and palpitations.
Cholecystitis
This disorder typically produces abrupt epigastric or right-upper-quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or the right shoulder. Associated findings commonly include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.
Coccidioidomycosis
In this disorder, pleuritic chest pain occurs with a dry or slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional chills, sore throat, backache, headache, malaise, marked weakness, anorexia, and a macular rash.
Costochondritis
Pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint.
Distention of colon’s splenic flexure
Central chest pain may radiate to the left arm in patients with this disorder. The pain may be relieved by defecation or the passage of flatus.
Esophageal spasm
In this disorder, substernal chest pain may last up to an hour and may radiate to the neck, jaw, arms, or back. It commonly mimics the squeezing or dull sensation associated with angina. Other signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.
Herpes zoster (shingles)
The pain of pre-eruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas—usually the thorax, arms, and legs—and the chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.
Hiatal hernia
Typically, this disorder produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially spicy foods and hot drinks.
Interstitial lung disease
As this disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.
Legionnaires’ disease
This disorder produces pleuritic chest pain in addition to malaise, headache, and possibly diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient suddenly develops a high fever and chills, and an initially nonproductive cough progresses to a productive cough with mucoid and then mucopurulent sputum and possibly hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.
Lung abscess
Pleuritic chest pain develops insidiously in a lung abscess along with a pleural friction rub and a cough that produces copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull on percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, fever, chills, fatigue, weakness, dyspnea, and clubbing.
Lung cancer
The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include a cough (sometimes blood-tinged), wheezing, dyspnea, fatigue, anorexia, weight loss, and fever.
Mediastinitis
This disorder produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Accompanying signs and symptoms include chills, fever, and dysphagia.
Mitral valve prolapse
Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or hours and may mimic the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.
Muscle strain
Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.
Myocardial infarction
The crushing substernal chest pain typically associated with an MI lasts from 15 minutes to hours. Typically unrelieved by rest or nitroglycerin, the pain may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.
Gender Cue: An MI may be difficult to diagnose in perimenopausal women because it may produce atypical symptoms, such as fatigue, nausea, dyspnea, and shoulder or neck pain, rather than chest pain.
Nocardiosis
This disorder causes pleuritic chest pain with a cough that produces thick, tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also cause fever, night sweats, anorexia, malaise, weight loss, and diminished or absent breath sounds.
Pancreatitis
Acute pancreatitis usually causes intense epigastric pain that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.
Peptic ulcer
In this disorder, sharp and burning pain usually arises in the epigastric region. This pain characteristically occurs hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.
Pericarditis
This disorder produces precordial or retrosternal pain that’s aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.
Plague
Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when the plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pleurisy
The sharp, even knifelike chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is usually unilateral and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid and shallow breathing, cyanosis, fever, and fatigue may also occur.
Pneumonia
This disorder produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.
Pneumothorax
Spontaneous pneumothorax, a life-threatening disorder, causes sudden severe, sharp chest pain that increases with chest movement; it’s typically unilateral and rarely localized. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.
Psittacosis
This disorder may produce pleuritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration.
Pulmonary actinomycosis
This disorder causes pleuritic chest pain with a cough that’s initially dry but later produces purulent sputum. The patient may also display hemoptysis, fever, weight loss, fatigue, weakness, dyspnea, and night sweats. Multiple sinuses may extend through the chest wall and drain externally.
Pulmonary embolism
This disorder produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness on percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less-common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck veins.
Pulmonary hypertension (primary)
Angina-like pain develops late in patients with this disorder, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.
Q fever
Q fever is a rickettsial disease caused by Coxiella burnetii, an organism found in cattle, sheep, and goats. Human infection usually results from exposure to contaminated milk, urine, feces, or other fluids from infected animals, but it may also result from inhalation of contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
Rib fracture
The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.
Sickle cell crisis
Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice.
Thoracic outlet syndrome
Often causing paresthesia along the ulnar distribution of the arm, this syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.
Tuberculosis
Pleuritic chest pain and fine crackles occur after coughing in a patient with tuberculosis. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath sounds.
Tularemia
Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Chinese restaurant syndrome
This benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.
Drugs
Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary artery disease, especially if he has received high doses for a prolonged period.
Special considerations
As needed, prepare the patient for cardiopulmonary studies, such as an electrocardiogram and a lung scan. Perform a venipuncture to collect a serum sample for cardiac enzyme and other studies. Explain the purpose and procedure of each diagnostic test to the patient to help alleviate his anxiety. Also explain the purpose of any prescribed drugs, and make sure that the patient understands the dosage, schedule, and possible adverse effects.
Keep in mind that a patient with chest pain may deny his discomfort, so stress the importance of reporting symptoms to allow adjustment of his treatment.
Pediatric pointers
Even children old enough to talk may have difficulty describing chest pain, so be alert for nonverbal clues, such as restlessness, facial grimaces, or holding of the painful area. Ask the child to point to the painful area and then to where the pain goes (to find out if it’s radiating). Determine the pain’s severity by asking the parents if the pain interferes with the child’s normal activities and behavior. Remember, a child may complain of chest pain in an attempt to get attention or to avoid attending school.
Geriatric pointers
Because older patients have a higher risk of developing life-threatening conditions (such as an MI, angina, and aortic dissection), you must evaluate chest pain carefully in these patients.
Patient counseling
Teach patients with coronary artery disease about the typical features of cardiac ischemia as well as the symptoms that should prompt them to seek medical attention. If the pain fails to disappear after sublingual nitroglycerin, lasts more than 20 minutes, or has a different pattern than the usual angina, the patient must be evaluated immediately.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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Chest Pain, Atypical (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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