Chest Pain

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
• Subcutaneous Tissue
  • Cellulitis
    • Diagnosis: History and physical exam (see skin and soft tissue infections)
• Muscles
  • Costochondritis
    • Diagnosis: History and physical exam (pain reproducible with palpation)
• Bones
  • Fractures
    • Diagnosis: Chest X-Ray

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