Approach To A Patient Presenting With Chest Pain

Medical students during their posting in medical ward are being taught how to approach a patient who presents with a complain of chest pain.
Chest pain is a very common presenting system of a variety of medical conditions. These may be trivial or life threatening.
A brief summary is given below on how to approach to a case of Chest Pain

Causes Of Chest Pain: 

1. Cardiovascular Causes: 

• Angina
• Myocardial Infarction
• Acute aortic dissection
• Pericarditis

2. Gastrointestinal Causes:

• Reflux esophagitis
• Esophageal spasm
• Peptic ulcer disease

3. Pulmonary Causes:

• Pneumonia
• Pulmonary embolism
• Pneumothorax

4. Musculoskeletal Causes:

• Chest wall injuries
• Costochondritis
• Metastasis to ribs 
• Herpes zoster

5. Emotional

• Depression

History And Physical Examination: As for any case initial history and examination are an important aspect in reaching a diagnosis for a patient who presents with chest pain. 

1. Character of Pain: Ask about the nature and character of pain. 

• Cardiac ischemia causes a tight and crushing chest pain
• Pain due to a dissecting aortic aneurysm is tearing in quality. 
• Pain due to underlying pericarditis or pleuritis gets worse on inspiration.  
• Chest pain from esophageal reflux has a burning quality. 
• Peptic ulcer related pain tends to be deep and gnawing. 

2. Location Of Pain: Both cardiac and esophageal reflux pain can be located retrosternally, as well as radiating to jaw and down into the left arm.

Pericarditis may cause pain radiating to the shoulders. Pain from an acute aortic dissection often radiates into the back while pulmonary pain can be located anywhere in the thorax.

3. Precipitating Factors: 

• Angina may be precipitated by effort, emotion, food and cold weather. When occurring at rest for more that 30 minutes it should be considered an infarct until proven otherwise.
• Esophageal reflux is often related to meals and precipitated by changes in posture, such as bending or lying down. 
• Breathing often worsens the pain from pulmonary origin but also sometimes of musculoskeletal causes , owing to movement of thorax. 

4. Relieving Factors: 

• Both esophageal spasm and angina may be relieved by glyceryl trinitrate which relaxes smooth muscle.
• Antacids will relieve pain of esophageal reflux but not angina.
• The pain associated with pericarditis is relieved by sitting forwards. 

5. Ask For Any History Of Trauma: A blunt injury to the chest may lead to chest wall tenderness. More severe injuries can lead to rib fractures and chest pain. 

6. Emotional Causes: Occasionally chest pain can be a presenting feature in patients suffering from depression, anxiety or after shocking bad news. . It is essential to rule out all organic causes before accepting emotional causes as the reason for chest pain. 

7. Check the Vitals: 

• Fever may be due to pneumonia, myocardial infarction, pericarditis and herpes zoster infection. 
• All causes of pain leads to tachycardia but sometimes palpating both upper and lower limb pulses help diagnosing aortic dissection in which the peripheral pulses are absent. 

8. JVP: The JVP is elevated with acute right ventricular failure. This may occur with an inferior MI or when more than 60%of pulmonary vascular supply is occluded by pulmonary embolism. 

9. Palpation Of Chest: 

• Tenderness on palpation would imply a musculoskeletal cause.
• Deviation of trachea occurs in the direction away from a tension pneumothorax. 
• Expansion of cehst is decreased on the affected side in both pneumonia and pneumothorax.
• Dullness to percussion will be noted in an area of consolidation with pneumonia.
• Pneumothorax leads to hyper resonance on percussion on affected side. 

10. Auscultation Of Chest: 

• The unilateral absence of breath sounds is consistent with a pneumothorax. 
• Bronchial breath sounds are audible over a segment of consolidation and sometimes above the level of an effusion. 
• Localized areas of crepitations are audible with lobar pneumonia, whereas wide spread crepitations suggest multilobar involvement or pulmonary edema secondary to left ventricular failure following a MI. 
• A friction rub may be auscultated with both pericardial and pleuritic disease. A differentiating feature is that the pericardial rub continues to be present when the patient holds the breath. 

11. Examining the Lower Limbs:

• A hot, swollen, tender calf may give a clue to an underlying deep vein thrombosis. 
• Pain on dorsiflexion of the foot (Homan's sign) also indicated DVT. 

Investigations: 

1. Complete Blood Count: An elevated white cell count will be expected in pneumonia and to a lesser extent in myocardial infarction. 

2. Cardiac enzymes: Following a myocardial infarction , the CK rises in 4-8 hrs and settles in 2-3 days. Increasing sensitivity is obtained by measuring cardiac troponins and CK-MB.  

3. ECG: Angina and MI will result in ECG changes. ST segment depression and T wave inversion is consistent with ischemia. Infarcts tend to produce ST segment elevation and Q wave formation. 

4. Chest X Ray: 

• The line of pleura may be visible and the absence of lung markings distal to this is the usual finding of pneumothorax.
• Area of consolidation on a chest film indicated pneumonia.
• Classically a wedge shaped shadow (base is distal) is seen in pulmonary embolism .
• Rib fractures may be seen on chest X ray.

Management: depend on the specific cause and diagnosis of chest pain.