Can’t Miss – Think about these etiologies first (quickly lethal)
- Myocardial Infarction
- Pulmonary Embolism
- Pneumothorax
- Aortic dissection
- Esophageal perforation
A quick, focused history helps:
- Do they have typical (see ACS) anginal pain? Do they have risk factors for myocardial infarction?
- Have they ever had blood clots before? A history of recent immobility?
- Do they have risk factors for a pneumothorax (COPD, etc.)?
- Is the pain a “ripping”/”tearing” quality with radiation to the back?
- Have they been vomiting?
Regardless, a patient presenting with chest pain is likely to receive a chest x-ray, EKG, and troponin to make sure these etiologies aren’t missed. Depending on the level of suspicion for a pulmonary embolism or aortic dissection, a CTA can be obtained (see Pulmonary Embolism)
Once these are ruled out, we can go one-by-one through the layers of the thoracic cavity to guide the differential.
Chest Wall
- Skin
- Shingles
- Diagnosis: History and physical exam
- Shingles
- Subcutaneous Tissue
- Cellulitis
- Diagnosis: History and physical exam (see skin and soft tissue infections)
- Cellulitis
- Muscles
- Costochondritis
- Diagnosis: History and physical exam (pain reproducible with palpation)
- Costochondritis
- Bones
- Fractures
- Diagnosis: Chest X-Ray
- Fractures
Lungs
- Pneumothorax
- Diagnosis: Physical Exam and Chest X-Ray
- Pulmonary Embolism
- Diagnosis: CTA (see PE)
- Pneumonia
- Diagnosis: History/Physical Exam and Chest X-Ray
- Neoplasm (presentation more likely to be subacute/chronic)
- Diagnosis: Imaging (likely Chest X-Ray followed by CT)
- Pleurisy
- Diagnosis: History and physical exam (pain worse with inspiration)
Heart
- Myocardial Infarction
- Diagnosis: EKG, Troponin, Echocardiogram (see ACS)
- Pericarditis
- Diagnosis: History (pain worse with inspiration, relieved by sitting forward), EKG (pan-ST-elevation), Echocardiogram (pericardial effusion)
Esophagus (all diagnosed by history)
- Mallory-Weiss Syndrome
- Boerhaave Syndrome
- GERD
- Esophagitis
Aorta
- Aortic Dissection
- Diagnosis: CTA