Differential Diagnosis by Location & Quality of Pain Evaluation of patients who complain of chest pain but are not in severe distress should proceed in a systematic fashion. The single most useful means of evaluation is the carefully elicited history supplemented by examination of the heart, lungs, abdomen, and peripheral vessels in conjunction with electrocardiography and chest X-ray. Consider most of the diagnostic possibilities at least briefly in every patient who presents with chest pain. A. Retrosternal Discomfort Retrosternal discomfort, especially if it is a tightness, pressure, or "squeezing" pain, should suggest serious underlying disease, for example, myocardial infarction, unstable angina due to atherosclerosis or valvular heart disease, pericarditis, dissection of the aorta, or pulmonary embolism. When the above mentioned diagnoses are excluded, esophageal disease (e.g., spasm, esophagitis) is the most common cause of retrosternal distress (see below). Because esophageal disease is relatively benign and rarely requires hospitalization, the more serious causes of retrosternal discomfort must be excluded with a high degree of certainty before concluding that the pain is of esophageal origin. Consider hospitalization for all adult patients with retrosternal pain for observation unless a condition not requiring hospitalization is diagnosed with certainty. B. Pleuritic Pain Pain that is markedly worse on inspiration should suggest pleurisy associated with pneumonia, pulmonary embolism, or isolated pleuritis. The pain of pneumothorax, pneumomediastinum, ruptured esophagus, and pericarditis frequently has a pleuritic component. The fleeting pain of a "stitch in the side" is often pleuritic in nature as well. Chest pain due to myocardial infarction may have a pleuritic component. One of the most serious causes of pleuritic chest pain, pulmonary embolism, is also one of the most difficult to diagnose given the widely varied presentations of the disease with nonspecific history and physical examination findings. Because of the increased mortality associated with misdiagnosis, consider pulmonary embolism in all patients presenting with pleuritic chest pain. C. Back or Abdominal Pain with Chest Pain Abdominal pain that is inferior to the xiphoid process and associated with chest pain should suggest intra-abdominal disease, dissecting aortic aneurysm, or possibly myocardial ischemia. In stable patients, CT scan of the chest and abdomen with intravenous contrast can reliably exclude the diagnosis of dissecting or ruptured aortic aneurysm. Even after aortic catastrophes are excluded, patients with chest pain often require hospitalization or admission to an observation unit to rule out myocardial ischemia. D. Musculoskeletal Discomfort Musculoskeletal disease with chest pain (Tietze's syndrome, rib fracture) is usually associated with marked tenderness localized over the affected site. Patients with chest pain referred from intrathoracic structures may also have some associated tenderness of superficial structures. Most patients with chest pain from musculoskeletal disorders can receive treatment in the emergency department and be discharged for outpatient follow-up care. Conditions Causing Chest Pain with Hypovolemia. A. Myocardial infarction with vagotonia ► Crushing chest pain, nausea by history ► Bradycardia, stable hypotension by examination ► Acute infarction pattern and bradycardia on ECG ► Nonspecific X-ray findings B. Aortic dissection ► Tearing chest pain, back pain, often history of hypertension ► Tachycardia, pulse deficits, progressive hypotension ► Nonspecific or may show ischemia or infarction pattern, left ventricular hypertrophy (ECG) ► Widened mediastinum, pleural fluid (X-ray). CT scan is more sensitive than X-ray C. Leaking upper abdominal aortic aneurysm ► Chest and epigastric pain (History) ►Tachycardia, pulsatile epigastric mass (Examination) ► Nonspecific ECG findings ► CT scan or ultrasound is more sensitive than X-rays. Conditions causing chest pain, hypotension with distended neck veins. A. Tension pneumothorax ► Hyperresonant hemithorax with decreased breath sounds, chest X-rays diagnostic, trachea deviates away from affected side B. Cardiac tamponade ► Faint heart sounds, ECG with diffuse low voltage or electrical alternans. Pulmonary edema rare. Echocardiography diagnostic. C. Cardiogenic shock (arrhythmogenic) ► ECG or cardiac monitor shows severe bradycardia or tachycardia (ventricular rate < 50 beats/min, usually < 40 beats/min, usually > 180 beats/min). Signs of myocardial ischemia may also be present. D. Cardiogenic shock (myocardial) ► Pulmonary edema almost always present. ECG almost always shows pattern diagnostic of infarction. E. Pulmonary embolism (massive). ► Physical examination, ECG, and chest X-ray show signs of right heart strain. Chest X-ray may show infiltrates, effusion, or truncation of pulmonary vasculature. Confirm diagnosis by ventilation-perfusion scanning, spiral CT scan of chest or pulmonary arteriography. Dr.Mahananda
