A patient comes in for “chest pain.” We determine right off that it’s “non-pleuritic,” meaning that it doesn’t feel worse every time they take a breath. We also find out if it’s continuous, or comes & goes; if it’s intermittent, how long does it last, how often does it occur? We proceed as follows:
FIRST: Rule out lethal diseases (#1 & #2 below). May send to ER for work-up.
- Gets worse with exertion
- Timing: Angina lasts 1-5 min. A Heart Attack pain can be ongoing.
- Associated symptoms along with the pain (these are important):
- shortness of breath, nausea/vomit, cold sweat, dizzy/lightheaded
- Coronary Artery Disease Risks (older age, smoking, hypertension, diabetes, high cholesterol, strong family history, same-day coke/meth, ? HIV)
- If suspect this, we work it up (see Diagnosing Coronary Artery Disease)
- BUT, if the above characteristics don’t fit, we don’t do tests “just in case”
2. Rule out ruptured Thoracic Aortic Aneurysm
- Very sudden onset severe, continuous pain
- “Sharp,” “tearing,” “ripping”
- >60 y.o. with Cardiac Risks / younger if has Marfan’s syndrome (very rare)
- If suspect Thoracic Aneurysm, we send to ER for Chest CT Scan
If none of above, we seek more common, benign causes (pain may be continuous or intermittent):
- Abdominal Diseases **
- Chest Wall Pain ** — worse with movement shoulder / torso, tender to pressing at a spot
- Herpes Zoster — red splotches in a stripe from spine to breastbone
- Breast Diseases — breast tissue is what’s tender to palpation
- Anxiety ** — symptoms of hyperventilation, context of onset, life stressors, often worse at night while in bed
** diagnosis of exclusion (no evidence for anything else, esp. any life-threatening diseases)
See also Non-Pleuritic Chest Pain — Full Text for more in-depth explanations and discussions.