Definition
A.Chest pain is a localized sensation of distress or discomfort that may or may not be associated with actual tissue damage.
Incidence
A.Chest pain is one of the most common complaints of adult patients. Causes can range from minor disorders to life-threatening diseases, so every patient must be assessed carefully.
Pathogenesis
A.Cardiac etiology: Ischemia, atherosclerosis, inflammation, or valvular problems due to angina, myocardial infarction (MI), pericarditis, endocarditis, dissecting aortic aneurysm, or mitral valve prolapse (MVP; see Table 13.3).
B.Musculoskeletal etiology: Muscle strain and inflammation due to costochondritis, chest wall syndrome, cervicodorsal arthritis, or intercostal myositis.
C.Neurologic etiology: Nerve inflammation and/or compression due to herpes zoster and nerve root compression.
D.Gastrointestinal (GI) etiology: Structural defects, inflammation, or infection due to gastroesophageal reflux disease (GERD), hiatal hernia, esophageal spasm, pancreatitis, cholecystitis, or peptic ulcer disease (PUD).
E.Pleural etiology: Inflammation, distension, or compression of pleural membranes due to pneumonia, pulmonary embolus, pulmonary hypertension (HTN), spontaneous pneumothorax, and lung and mediastinal tumors.
F.Psychogenic etiology: Stress due to anxiety, depression, or panic disorders.
Predisposing Factors
A.These vary depending on the etiology of pain.
Common Complaints
A.Primary complaint: Pain somewhere in the chest.
B.Levine sign
: Placing the fist to the center of the chest to demonstrate pain.
C.Fatigue.
D.Cough.
E.Indigestion.
F.Dyspnea.
G.Syncope.
H.Palpitations.
I.Profound fatigue.
Other Signs and Symptoms
A.Pain may be typical of angina and MI.
B.Musculoskeletal pain may be relieved by position change, aggravated by body movement, reproducible, or caused by injury or trauma.
C.Neurologic pain is associated with skin lesion if herpes zoster is the causative agent.
D.GI pain may be associated with meals, certain positions, belching, or an acid brash
taste in mouth, or it may be referred to other sites.
E.Pleural pain is usually accompanied by cough, upper respiratory infection (URI) symptoms, or shortness of breath (SOB).
F.Psychogenic pain or pressure along with SOB and dizziness may be associated with a specific event or time.
Subjective Data
A.How long has the patient had chest pain?
B.Has the patient ever been treated for chest pain? What treatments, tests, and medications (such as nitroglycerin) were used?
C.What precipitates and relieves the patient’s chest pain?
1.Precipitating factors: Exertion, taking a deep breath, eating, cold, stress, and sexual intercourse.
2.Alleviating factors: Resting, eating, taking an antacid, taking nitroglycerin, and positional change.
D.Inquire about character of pain:
1.Location: Neck, throat, chest, epigastric area, and shoulder.
2.Radiation: Neck, throat, shoulder, lower jaw, and upper extremity:
a.Radiation to one or both arms is a predictor of acute MI.
b.Chest pain that radiates between the scapulae may be due to aortic dissection.
3.Quality: Squeezing, pressure, strangling, fullness, heavy weight, tightening, constriction, and ripping/tearing (acute aortic dissection).
4.Intensity: Abrupt onset, gradually getting worse, dull, or insidious.
5.Duration: Seconds, minutes, hours, or years.
6.Frequency: Intermittent, occurs every morning/evening.
E.Are other associated symptoms present?
F.Discuss any risk factors the patient may have for cardiac disease: Smoking, hyperlipidemia, HTN, sedentary lifestyle, diabetes, and family history.
G.Review medical history as noted earlier.
H.Review all medications, including prescription (such as sildenafil), over-the-counter (OTC) and herbal products.
I.Review recreational/illicit drug use.
J.Inquire about any new physical labor if musculoskeletal etiology is suspected.
K.Has the patient had any trauma (including domestic violence)?
L.Has the patient had a recent infection?
Physical Examination
A.Check temperature (if infection is suspected), pulse, respirations, blood pressure (BP), and pulse oximetry.
B.Inspect:
1.Inspect general appearance:
a.Appearance of discomfort/distress.
b.Any appearance of respiratory distress.
c.Evaluate jugular venous distention (JVD).
d.Note patient position: Sitting, lying, squatting. Relief of chest pain with recumbency suggests MVP; relief with squatting suggests hypertrophic cardiomyopathy. Noncardiac chest pain may be present along with cardiac chest pain.
2.Inspect skin for diaphoresis, jaundice, pallor, herpes zoster lesions, rash, or cyanosis.
3.Inspect chest wall for herpes zoster lesions or signs of trauma.
4.Inspect eyes by performing funduscopic exam.
5.Inspect legs for signs of phlebitis: Unilateral swelling, cyanosis, venous stasis, and diminished pulses.
6.Inspect neck for enlarged thyroid and lymph nodes, midline trachea, and JVD.
C.Palpate:
1.Palpate chest wall for tenderness and swelling. Chest pain present in only one body position is usually not cardiac in origin.
2.Palpate abdomen for masses, tenderness, bounding pulses, organomegaly, and ascites.
3.Palpate femoral and distal pulses.
D.Auscultate:
1.Auscultate carotid arteries for bruits.
2.Auscultate lungs for crackles, wheezes, equal breath sounds, and pleural rub.
3.Auscultate abdomen for bruits and bowel sounds.
4.Auscultate heart for murmurs, rubs, clicks, irregularities, or extra sounds.
E.Neurologic exam: Perform this exam if neurologic etiology is suspected.
Diagnostic Tests
A.Testing depends on information collected in the exam. A normal physical exam, ECG, and/or lab test results in a patient with chest pain but does not rule out coronary heart disease (CHD). Typical tests include the following:
1.ECG.
2.Chest radiography, whenever diagnosis of chest pain is not clear.
3.Echocardiogram.
4.Stress test.
5.Cardiac catheterization.
6.Barium tests.
7.Endoscopy to rule out GI etiology.
8.Esophageal pH, low.
9.Lab tests:
a.Troponin I or T.
b.Myoglobin.
c.Creatine kinase (CK).
d.CK MB isoenzyme creatine kinase-muscle/brain (CK-MB)—may be useful if the initial troponin determination is abnormal for suspected reinfarction.
e.C-reactive protein (CRP).
f.B-type natriuretic peptide (BNP) for clinical findings/risk of HF.
g.D-dimer for suspected venous thrombotic event (deep vein thrombosis [DVT] or pulmonary embolism [PE]).
Differential Diagnoses
A.Cardiac causes:
1.CHD:
a.Acute MI: Chest pain lasting more than 15 minutes.
b.Unstable angina pectoris.