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Symptoms
 
 

Chest Pain

 
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Overview

Chest pain is a very common presenting complaint, and the most pressing concern is to rule out life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection and tension pneumothorax. A thorough history is vital for differentiating between these causes and other less emergent conditions that may cause chest pain.

Aetiology

  • Causes of Chest Pain

  • Cardiac

  • Stable angina
  • Acute coronary syndrome - unstable angina, NSTEMI, STEMI
  • Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
  • Non-ischaemic - pericarditis, myocarditis, myocardial contusion
  • Non-Cardiac

  • Vascular - aortic dissection, pulmonary embolism
  • Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
  • Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
  • Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
  • Psychogenic - panic disorder, malingering

History of Presenting Complaint

  • Site  

    Where the pain is - central, the left or right side, the ribs, or generalised.
  • Retrosternal chest painReflux, angina
  • Pain in chest wall / ribs Suggestive of a musculoskeletal cause - unlikely to be anginal
  • Onset

    Whether the pain began suddenly or gradually, and what the patient was doing at the time.
  • Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
  • Onset during exertionSuggestive of stable angina if typical ischaemic pain
  • Onset post traumaMay represent pneumothorax or rib fractures
  • Character

     The type of pain - sharp, dull, tight, crushing, burning or tearing.
  • Central, crushing chest painTypical of acute coronary syndrome
  • Tearing pain that radiates to the backCharacteristic of aortic dissection
  • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE, chest wall pain (unlikely anginal)
  • Radiation  

    Whether the pain radiates anywhere else, such as the shoulder, arm, jaw or back.
  • Pain radiating to the shoulders / arms or jawTypical of acute coronary syndrome
  • Pain radiating to the backSuggestive of aortic dissection
  • Associated Symptoms

    Whether the pain is associated with any other symptoms.
  • Nausea, vomiting and diaphoresisSuggestive of angina / acute coronary syndrome
  • FeversSuggestive of pneumonia, pericarditis or costochondritis
  • Shortness of breathSuggestive of respiratory cause such as pneumonia, pneumothorax or PE
  • CoughSuggestive of pneumonia or reflux
  • Sour taste / acid refluxSuggestive of reflux pain
  • Timing

    How long the pain has been going on for.
  • Central crushing chest pain lasting >20 minutesSuggestive of acute coronary syndrome rather than stable angina
  • Exacerbating Factors

    Whether anything makes the pain worse, such as breathing in or sitting forward.
  • Exertional chest painSuggestive of cardiac pain
  • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE or chest wall pain (unlikely anginal)
  • Brought on with foodSuggestive of reflux
  • Worsened by sitting forward or lying downSuggestive of reflux
  • Alleviating Factors

    Whether anything they've tried has improved or resolved the pain.
  • Relief with GTNStrongly suggestive of cardiac ischaemia, though GTN may also relieve oesophageal pain
  • Relief with reflux medsMore likely to represent reflux pain
  • Relief with passing gasSuggestive of ‘pseudo-angina’ - gas in stomach or splenic flexure
  • Improved with sitting forwardSuggestive of pericarditis
  • Severity

  • How severe the pain is out of 10, with 10 being the worse possible pain.
  • How the pain is impacting the patient’s life, such as work, hobbies or even mobility.

Extra Credit

  • High Likelihood of Acute Coronary Syndrome

  • Pressure-like sensation (e.g. tight or crushing)
  • Radiating to one or both arms
  • Associated with exertion, nausea, vomiting or diaphoresis
  • Low Likelihood of Acute Coronary Syndrome

  • Stabbing pain
  • Pleuritic pain
  • Positional pain
  • Inframammary pain
  • Reproducible with palpation
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