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Chapter 7 • Chest Pain 91
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Complete Blood Count
A complete blood count (CBC) is obtained to detect
an elevated white blood cell count that occurs with
infection. Hemoglobin and hematocrit levels are
useful if anemia is suspected as an underlying cause of
chest pain.
Esophageal pH
When GERD is suspected, 24-hour esophageal pH
monitoring is performed to document pathological acid
reux.
Endoscopy
Upper endoscopy with biopsy is necessary to document the type and extent of tissue damage in GERD. A
normal endoscopy, however, does not rule out mild
gastric reux disease.
Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate value will be elevated with inammation, such as in arthritis and
pericarditis. The test is not specic for a particular
disease.
DIFFERENTIAL DIAGNOSIS
Common Causes of Emergent Chest Pain
Acute Myocardial Infarction
Assessment of the patient experiencing acute chest
pain must rst focus on the potential diagnosis of myocardial infarction (MI) to facilitate prompt initiation of
treatment to limit infarct size. The patient with an acute
MI generally describes a sudden onset of pain at rest.
It is a persistent, often severe, deep, central chest pain
and can radiate, as does angina, to the throat or neck,
across both sides of the chest to the shoulder, and/or
down the medial aspect of either or both arms. Rest or
nitroglycerin does not relieve the pain. The chest pain
is often associated with shortness of breath, nausea,
vomiting, and diaphoresis.
The quality of the pain or discomfort is generally
more intense than any previously experienced anginal symptoms. Patients can also express a sense
of impending doom. Quick review for positive risk
factors (men age 45 years and older; women age
55 years and older; cigarette smoker; hyperlipidemia; hypertension; diabetes; obesity; history of
CAD; family history of CAD) is useful. Objective
evidence of an MI can include skin pallor, cool
diaphoretic skin, and transient paradoxical S2. The
patient can be hypertensive or hypotensive.
The patient with severe chest pain or a suspected MI
should be placed on a cardiac monitor as soon as possible. Observe for premature ventricular contractions
and classic electrocardiographic changes that indicate
MI, including ST segment elevations, T wave inversions, and Q waves. Performing a 12-lead ECG and
determining levels of cardiac isozymes will help conrm or rule out an MI.
Aortic Dissection
The patient often is in a great deal of distress, describing the unrelenting chest pain as ripping and tearing
and radiating to the interscapular region, jaw, neck, or
lower back. Physical examination reveals severe hypertension and unequal or absent peripheral pulses.
Chest radiography demonstrates a wide mediastinum
with extension of the aortic wall beyond the calcic
border. A CT scan or MRI can be ordered, but aortography remains the gold standard. Patients with suspect
aortic dissection should be referred for emergent care.
Acute Coronary Insufficiency
Acute coronary insufciency refers to those situations
in which chest pain is caused by lack of oxygen to
the myocardium but there is no evidence of infarct.
The patient reports severe, oppressive, constricting,
retrosternal discomfort lasting longer than 30 minutes.
The patient may report prior history of MI or angina.
The ECG can show intermittent ischemic changes or
be normal. Cardiac isozymes are normal.
Pulmonary Embolus
Patients presenting with PE usually report sudden
onset of severe sharp, crushing, nonradiating chest
pain if there is an embolus impacted in a major artery.
Infarction of the pulmonary parenchyma closer to the
pleural surface will cause pleuritic chest pain often
accompanied by the sudden onset of dyspnea and
hemoptysis. Patients frequently express feelings of
impending doom.
A review of risk factors will likely reveal one or
more of the following: older age, prior venous thromboembolism, prolonged immobility or paralysis, cancer, heart failure, other chronic disease, pelvic or
lower extremity surgery, recent pregnancy or delivery,
obesity, oral contraceptive use, or varicose veins.
Physical ndings include restlessness, tachycardia,
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tachypnea, fever, diminished breath sounds, crackles
and/or wheezes, and possible pleural friction rub.
There can be signs of thrombophlebitis of the
extremities. Initial diagnostic tests should include
chest radiograph and ECG; these can both be normal
but if clinical signs still point to PE, referral for consultation and further tests, including ABGs, venous
Doppler studies, ventilation/perfusion scans, and
pulmonary angiography, are indicated.
Pneumothorax
Pneumothorax can be a life-threatening event, especially if the patient has underlying COPD or asthma.
The patient reports sharp or tearing chest pain that can
radiate to the ipsilateral shoulder. Sudden onset of
shortness of breath is also associated with spontaneous
pneumothorax. Objective ndings include decreased
or absent breath sounds on the affected side, tachycardia, tachypnea, and possible deviated trachea. A chest
radiograph is needed to evaluate the possible complete
or partial collapse of the lung.
Arrhythmias
Patients report palpitations and/or forceful heartbeats.
These arrhythmias can be the result of myocardial ischemia, cocaine abuse, or such conditions as prolapsed
mitral valve or anxiety. Syncope associated with palpitations indicates a more serious cardiac arrhythmia.
Congenital Coronary Anomalies
The coronary arteries can arise abnormally, take an
abnormal course, or have stulous connections to other
structures, resulting in exertional chest pain that can
lead to sudden death in the young athlete. The child or
adolescent can have a history of moderate to severe
chest pain during or after exercise. Risk factors include
the following: family history of sudden death at an
early age, heart disease, or seizures; history of lightheadedness or loss of consciousness during exercise;
and tall and lanky body type with double-jointedness.
Referral to a pediatric cardiologist is warranted.
Common Causes of Nonemergent
Chest Pain
Stable Angina
Stable angina refers to chest pain typically described as
substernal chest pressure or heaviness, radiating to the
left shoulder and arm, neck, or jaw. The pain onset is
usually gradual, brought on and exacerbated by exercise and stress; it is associated with nausea, diaphoresis, and shortness of breath and is alleviated with rest
and/or nitroglycerin. Pain typically lasts 2 to 10 minutes.
Physical examination is usually normal. An S4 gallop
can be transiently present during an episode of pain.
Tests for angina include performing an ECG during an
episode of pain, which can show ST segment depression and T wave inversions, or the ndings can be
normal.
Myocarditis
Myocarditis is an inammation of the myocardium and
is commonly caused by viruses. The heart is unable to
contract properly because the inammatory process
interferes with the contractile function of the myocardial cells and eventually leads to cell death. It is frequently accompanied by pericarditis. The chest pain is
caused by ischemia or arrhythmia. Patients have fever
and dyspnea and can have evidence of heart failure.
Heart murmurs and friction rubs can be heard. Chest
radiographs show cardiomegaly.
Pericarditis
The pain associated with pericarditis is described as
sharp, located in the center of the chest, short-lived,
episodic, and radiating to the back in the trapezial area.
The pain is worse when the patient is supine and sitting, whereas leaning forward often reduces the intensity of the pain. Shallow breathing can be an associated
symptom in an effort to avoid pain. Dyspnea can be
present with compression of the bronchial tree by a
large pericardial effusion. Risk factors for pericarditis
include recent viral or bacterial infection, recent MI,
uremia, myxedema, and history of autoimmune disease. Objective signs include fever before the onset of
pain, tachycardia, and pericardial friction rub. The rub
is pathognomonic for pericarditis but is found in only
60% to 70% of patients with pericarditis. Diagnostic
tests show elevated white blood cells and erythrocyte
sedimentation rate and diffuse ST segment elevation in
the early stages. Chest radiography can be normal or
show effusion with an increase in cardiac shadow.
Aortic Stenosis
Aortic stenosis can cause exertional chest pain. Associated symptoms include fatigue, palpitation, dyspnea
on exertion (DOE), dizziness, and syncope. Physical
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examination will reveal a loud, harsh crescendodecrescendo murmur best heard at the second right
intercostal space with the patient leaning forward. The
murmur can radiate to the neck and is often associated
with a thrill. An echocardiogram will provide diagnostic evidence of aortic stenosis.
Mitral Regurgitation
Symptoms of mitral regurgitation are similar to those
of aortic stenosis: they include exertional substernal
chest pain, fatigue, palpitation, dizziness, DOE, and
syncope. The murmur associated with mitral regurgitation is holosystolic and blowing and often is heard
best at the apex in the left lateral position. The
murmur decreases with inspiration and can radiate to
the left axilla and occasionally to the back. Again,
echocardiography will provide evidence of mitral
regurgitation.
Pneumonia
Signs and symptoms of pneumonia include pleuritic
chest pain; a productive, moist cough with dark sputum; shortness of breath; and fever and chills. Risk
factors include ineffective cough reex, inability to
swallow, advanced age, or very young age. Auscultation of the lungs reveals diminished breath sounds
over affected areas, and crackles and wheezes can be
heard. Rales and rhonchi are frequently heard on auscultation of the lungs. Dullness with percussion is
heard over areas of consolidation. Vocal fremitus is
positive. In addition, physical ndings can include
tachycardia, tachypnea, bronchophony, and egophony.
Chest radiography, sputum culture, and ABGs will
further support the diagnosis of pneumonia. Followup chest radiographs are indicated after pneumonia
because lung tumors can be hidden by pneumonia.
The very young and very old are most often hospitalized for observation and treatment of pneumonia.
Healthy adults are usually managed on an outpatient
basis.
Mitral Valve Prolapse
Patients with chest pain from mitral valve prolapse report
a range of symptoms, including arrhythmias, palpitations, and anxiety. Physical examination can be normal,
or a midsystolic click can be heard over the apex while
the patient is sitting or squatting. An echocardiogram will
provide evidence of mitral valve prolapse.
Pleuritis
Pleuritic chest pain occurs suddenly and is worsened
by deep breathing, coughing, and sneezing. Pleuritic
chest pain can be a manifestation of pneumonia or can
represent pleural inammation, especially following
a viral upper respiratory tract infection. Physical examination of the chest can be normal, or a pleural
friction rub can be heard over the area of inammation. The patient’s respiration rate is normal, but respirations are often shallow or guarded. Unless pneumonia is suspected, no diagnostic tests are indicated
because the cause of pleuritic chest pain is likely of
viral etiology.
Esophagitis
Esophagitis or esophageal spasm symptoms often
mimic angina. In fact, sublingual nitroglycerin can also
relieve the symptoms, but usually relief takes longer
than the 3 to 5 minutes for angina to be relieved.
Patients frequently report that the pain is worse after
eating spicy foods or large meals or if they lie down
after eating. They sometimes report a sour taste in their
mouth. Physical examination is normal except for possible epigastric tenderness with palpation. The most
reliable way to detect reux as the cause of chest pain
is to correlate episodes of chest pain with results of
24-hour esophageal pH monitoring.
Chest Trauma
Rib fractures usually follow trauma. Pain is made
worse by deep breathing. The patient’s respirations are
shallow, and pain is exacerbated by palpation in
the area of the fracture. Chest or rib radiographs will
conrm suspected rib fractures.
Costochondritis and Tietze Syndrome
Costochondritis and Tietze syndrome are both identied by severe pain with palpation along the anterior
cartilage where the ribs meet the sternum. Deep breathing and movement of the chest wall intensify the pain.
In Tietze syndrome, swelling also occurs along this
border.
Herpes Zoster
Herpes zoster is manifested by unilateral chest pain that
follows a dermatome. The pain is usually described as
burning, stabbing, or pruritic. Early in the course of the
disease, no objective manifestations are present. As the
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course of herpes zoster progresses, a vesicular rash
appears in the area of pain (see Chapter 25).
Peptic Ulcer Disease
Subjective manifestations of peptic ulcer disease
include episodes of pain 1 to 3 hours after eating. The
pain can awaken the patient at night and is frequently
relieved by antacids or eating. The patient can report
hematemesis and/or melena. A CBC can show irondeciency anemia. Personal or family history of ulcer
disease can be a risk factor, as well as cigarette smoking and alcohol abuse. Upper GI radiography and
endoscopy are diagnostic tests that can conrm peptic
ulcer disease.
Cholecystitis
Cholecystitis is reported as colicky, intermittent epigastric or right upper quadrant pain that often follows
a high-fat meal. Nausea and vomiting can accompany
the pain, which often radiates to the right infrascapular
area. Physical examination can show a positive
Murphy sign, as indicated by tenderness in the region of
the gallbladder. The gallbladder can be distended and
palpable. Gallbladder ultrasonography is the most important diagnostic test in the evaluation of this problem.
Acute Pancreatitis
Acute pancreatitis occurs as the sudden onset of
severe, steady upper epigastric or left upper quadrant
abdominal pain, which frequently radiates to the left
anterior chest, shoulders, or back. The pain is worse in
the supine position. The patient appears restless, and
pain can be associated with nausea and severe vomiting, hypotension, and unexplained shock. Left upper
quadrant abdominal pain with palpation is present.
Determination of serum amylase and lipase levels conrms the diagnosis. A rise in amylase level is seen 2 to
12 hours after the onset of symptoms. The lipase level
returns to normal slower than the amylase level and
thus is more useful in diagnosing pancreatitis later in
its course. Pancreas ultrasonography and CT are necessary to show positive evidence of pancreatitis.
Lung and Mediastinal Tumors
Lung and mediastinal tumors can be manifested by
chest pain. Associated symptoms include shortness of
breath, cough, and hemoptysis. Pneumonia is often the
initial diagnosis, and persistence of symptoms after
treatment can lead to further investigation for tumors.
Risk factors include a smoking history and family
history of cancer. Physical examination can be normal
or reveal diminished breath sounds in the area of the
tumor. Dull sounds on percussion of the chest can be
an objective manifestation of a chest mass. Chest radiography and CT of the chest are diagnostic tools to
identify these lesions. Bronchoscopy is performed to
obtain a biopsy.
Cocaine Use
Cocaine increases the metabolic requirement of
the heart for oxygen and decreases the supply of oxygen, producing myocardial ischemia and chest pain.
Cocaine causes adrenergic stimulation, thus increasing heart rate, blood pressure, and left ventricular
contractility. Concomitantly, myocardial oxygen
supply declines because of cocaine-induced vasoconstriction of the coronary arteries. ECGs, serial
cardiac enzymes, and urine drug screens are useful
diagnostic tools.
Psychogenic Origin
Adults and adolescents with a history of a recent
stressful situation can present with chest pain. Physical
examination is negative.
Pleurodynia
Group B coxsackieviruses can cause pleurodynia.
Presentation is usually a sudden, severe onset of stabbing, paroxysmal pleuritic pain over the lower rib cage
and substernal area. Deep breathing aggravates the
pain. Fever, headache, malaise, and unproductive
cough are usually present. The chest examination is
negative except for pleuritic friction rub in 25% of
cases. The condition lasts from 1 to 14 days.
Precordial Catch Syndrome
Recurrent brief episodes of sudden, sharp, but not distressing pain occurring at rest or during mild exercise
can indicate precordial catch syndrome. It is localized
near the apex of the heart and along the left sternal
border or beneath the left breast. It is seen in adolescents and is benign in nature.
Chapter 7 • Chest Pain 95
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Emergent Chest Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute myocardial
infarction
Aortic dissection Sudden, tearing pain in anterior
Acute coronary
artery insufficiency
Pulmonary embolus Acute onset; sense of doom;
Pneumothorax Sharp or tearing pain, can radiate
Arrhythmias Palpitations, dizziness, forceful
Congenital coronary
anomalies
ABG, arterial blood gas; aPTT, activated partial thromboplastin time; BP, blood pressure; CAD, coronary artery disease; CF, cystic fibrosis;
CHD, coronary heart disease; CT, computed tomography; DVT, deep venous thrombosis; ECG, electrocardiogram; MI, myocardial infarction;
MRI, magnetic resonance imaging; PT, prothrombin time; SVT, supraventricular tachycardia.
Severe, oppressive, constricting
retrosternal discomfort, radiating
to left or right arm, neck, and/or
jaw, lasting .30 min; diaphoresis, dyspnea, nausea; history of
CAD, cigarette smoker, positive
family history of CAD, history of
elevated lipids
or posterior chest; migrates to
arms, abdomen, and legs
Severe, constricting retrosternal
chest pain lasting .30 min;
anxiety, diaphoresis, dyspnea;
prior history of angina or MI
pleuritic pain, restlessness; mild
to severe pain; hemoptysis;
history of DVT, recent trauma
to lower extremity, surgery; oral
contraceptives
to ipsilateral shoulder; dyspnea;
children with asthma, CF, or
Marfan syndrome at risk
heartbeats; history of CHD, fever,
and medications (sympathomimetics and b-adrenergic agents);
history of cocaine abuse
In children and adolescents, history
of moderate to severe chest pain
during or following exercise;
family history of early sudden
death
Hypertension or hypotension,
cardiac arrhythmia,
paradoxical S
2
Pulse deficits, hypertension;
possible neurological
changes in legs; aortic
diastolic murmur
Restlessness, cool and
clammy skin, tachycardia
Fever, dyspnea, cough,
tachycardia, tachypnea,
diminished breath sounds;
crackles, wheezing
Tachycardia; diminished breath
sounds; crackles, wheezing
SVT 5 tachycardia of
150-250 beats/min, sinus
or ventricular tachycardia,
irregular pulse
Can have murmurs, clicks,
decreased lower extremity
pulses, irregular pulse, BP
Serial ECGs, serial
cardiac enzymes,
nuclear scan,
troponin, T & I, chest
radiograph,
echocardiogram,
angiography
Echocardiogram,
angiography, CT scan/
MRI, emergency
referral, chest
radiograph
ECG, isoenzymes
PT/aPTT, ABGs,
chest radiograph,
ventilation/perfusion
scans, CT, pulmonary
angiography
Chest radiograph, ABGs
ECG during episode,
Holter 24-hour ECG
ECG, referral to
pediatric cardiologist
DIFFERENTIAL DIAGNOSIS OF Common Causes of Nonemergent Chest Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Stable angina Substernal chest pressure
Myocarditis Chest pain; history of fever,
following exercise or stress and
relieved by rest or nitroglycerin;
nausea, SOB, diaphoresis,
sternal chest pressure
dyspnea
Normal examination; possible
transient S
4
Heart murmur, friction rub,
fever
ECG during episode of
chest pain
ECG, chest radiograph
Continued
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Nonemergent Chest Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pericarditis Sharp, stabbing pain referred to
left shoulder or trapezius ridge,
usually worse during coughing
or deep breathing; can be
relieved by sitting forward;
history of viral or bacterial
infection, autoimmune disease
Aortic stenosis Chest pain on exertion,
substernal and anginal in
quality; fatigue, palpitations,
DOE, dizziness, syncope
Mitral regurgitation Exertional chest pain, fatigue,
palpitations, dizziness, DOE,
syncope
Pneumonia Productive cough of yellow or
green or rust sputum, dyspnea,
pleuritic pain
Mitral valve prolapse Chest pain, varies in location and
intensity; palpitations; anxiety;
nonexertional pain of short
duration; history of Marfan
syndrome
Pleuritis Mild, localized chest pain, worse
with deep breathing; recent URI
Esophagitis Substernal pain worse after
eating and lying down; sour
taste in mouth
Chest trauma (rib
fracture)
Costochondritis Pain along sternal border,
Herpes zoster Unilateral chest pain; painful rash Normal breath sounds; vesicu-
Peptic ulcer disease Epigastric pain 1 to 2 hours
Cholecystitis Right upper quadrant abdominal
History of injury or trauma; pain
with deep breaths; splinting of
chest wall
increases with deep breaths;
history of exercise, URI, or
physical activity
after eating, can be relieved
by antacids; hematemesis and
melena; risk factors include
smoking and alcohol overuse
pain radiating to right chest,
often after eating high-fat meal;
nausea and vomiting
Fever before onset of pain,
tachycardia, pericardial
friction rub
Radial pulse diminished;
narrow pulse pressure;
loud, harsh, crescendodecrescendo murmur heard
best at second right ICS with
patient leaning forward; thrill
Holosystolic, blowing, often
loud murmur heard best at
apex in left lateral position and
decreases with inspiration;
murmur can radiate to axilla
and possibly back
Fever; tachycardia, tachypnea;
inspiratory crackles; vocal
fremitus; percussion dull or
flat over area of consolidation;
bronchophony; egophony
Arrhythmias, possible midsys-
tolic click heard over apex;
heard best while patient is in
sitting or squatting position;
thoracoskeletal deformity
common in children
Shallow respirations, local
tenderness, pleural
friction rub
Epigastric pain with palpitation Esophageal pH
Shallow respirations; chest wall
pain on palpitation
Pain with palpitation over
costochondral joints; normal
breath sounds
lar rash along dermatome
Tenderness to palpitation in
epigastric area; signs of
hypovolemia
Positive Murphy sign; palpable
gallbladder
WBC, ESR, ECG, chest
radiograph
Echocardiogram, ECG,
chest radiograph
Chest radiograph, ECG,
echocardiogram
Chest radiograph,
sputum cultures,
ABGs
ECG, echocardiogram
None initially
Chest radiograph
None
None
Upper GI radiograph,
upper endoscopy,
CBC
Gallbladder ultrasound
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Nonemergent Chest Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute pancreatitis Severe left upper quadrant
abdominal pain radiating into
left chest; pain worse in supine
position; nausea, vomiting, fever
Lung tumors Chest pain, SOB, cough,
hemoptysis, history of cigarette
smoking; history of pneumonia
Cocaine use Chest pain, SOB, diaphoresis, nau-
sea; can relate to substance use
Psychogenic origin Precordial chest pain, history of
stressful situations
Pleurodynia Severe, acute onset, stabbing,
paroxysmal, pleuritic pain over
lower rib cage and substernal
edge; headache, malaise,
nonproductive cough
Precordial catch
syndrome
CBC, complete blood cell count; CT, computed tomography; DOE, dizziness on exertion; ECG, electrocardiogram; ESR, erythrocyte sedimentation
rate; GI, gastrointestinal; ICS, intercostal space; SOB, shortness of breath; URI, upper respiratory tract infection; WBC, white blood cell count.
Sudden, sharp, nondistressing
pain near apex of heart; seen in
adolescents
Left upper abdominal pain with
palpation; hypotension
Normal exam or diminished
breath sounds over tumor
and dull percussion sound
over tumor
Tachycardia, hypertension ECG, serial cardiac
Normal exam ECG, chest radiograph
Pleural friction rub 25% of
time; chest examination normal; fever usually present
Normal examination None
Serum analysis,
pancreas ultrasound
or CT scan
Chest radiograph,
CT scan of chest,
bronchoscopy
enzymes, drug screen
None
REFERENCES AND READINGS
Bettmann MA, Lyders EM, Yucel EK, Khan A, Haramati LB,
Ho VB, Expert Panel on Cardiac Imaging. Acute chest pain—
suspected pulmonary embolism [online publication]. Reston
(VA): American College of Radiology (ACR); 2006.
Canadian Cardiovascular Society, American Academy of Family
Physicians, American College of Cardiology, American Heart
Association, Antman EM, Hand M, Armstrong PW, Bates ER,
Green LA, Halasyamani LK, et al: 2007 focused update of the
ACC/AHA 2004 guidelines for the management of patients with
ST-elevation myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on
Practice Guidelines, J Am Coll Cardiol 51:210, 2008.
Cava J, Saygor P: Chest pain in children and adolescents, Pediatr
Clin North Am 51:1553, 2004.
Cayley WE: Diagnosing the cause of chest pain, Am Fam Physician
72:2012, 2005.
DeVon HA, Ryan CJ: Chest pain and associated symptoms of acute
coronary syndromes, J Cardiovasc Nurs 20:232, 2005.
Eslick GD, Coulshed DS, Talley NJ: Diagnosis and treatment of
noncardiac chest pain, Natl Clin Pract Gastroenterol Hepatol
2:10, 2005.
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults: Executive summary of the third report of
the National Cholesterol Education Program (NCEP) Expert
Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III), JAMA
285:2486, 2001.
Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT,
Hunninghake DB: Implications of recent clinical trials for the
National Cholesterol Education Program Adult Treatment Panel
III Guidelines, Circulation 110:227, 2004.
Imazio M, Cecchi E, Demichelis B, Chinaglia A, Ierna S, Demarie
D: Myopericarditis versus viral or idiopathic acute pericarditis,
Heart 94:498, 2008.
Kruip MJ, Leclercq MG, van der Heul C, Prins MH, Büller HR:
Diagnostic strategies for excluding pulmonary embolism in clinical outcome studies: a systematic review, Ann Intern Med
138:941, 2003.
Lane JR, Ben-Shachar G: Myocardial infarct in healthy adolescents,
Pediatrics 120:1, 2007.
Lange RA, Hill LD: Acute pericarditis, N Engl J Med 351:2195,
2004.
Lee TH, Goldman L: Evaluation of the patient with acute chest pain,
N Engl J Med 342:1187, 2000.
Reddy S, Singh H: Chest pain in children and adolescents, Pediatr
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C H A P T E R
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8
Confusion in Older Adults
onfusion is a symptom rather than a disease
state. It is the inability to think quickly or
C
time, person, or place and can demonstrate impaired
cognitive function. Older adults are far more likely
to experience an acute confusional state as a result
of hospitalization or surgery, systemic or electrolyte
imbalance, organ failure, excessive medication, nutritional deciency, systemic infection, or cerebral insufciency, such as stroke or transient ischemic attacks.
When an older patient presents with confusion, the
differential diagnosis includes delirium, dementia, or
depression.
characterized by abrupt onset, reduced level of acute
consciousness, and sleep/wake cycle disturbance. Delir-
ium is a medical emergency and can occur as a result of
medications, alcohol use or alcohol withdrawal, narcotic
reaction or narcotic withdrawal, Wernicke-Korsakoff
syndrome (vitamin B12 deciency), hepatic encephalopathy, acute illness, chronic illness, interacting diseases, or
trauma (e.g., head injury).
brain function, affects thinking but not level of consciousness. A common early complaint in dementia
is forgetfulness, with loss of concentration and loss
of memory. Causes of dementia can be classied
as reversible (or partially reversible), modiable, or
irreversible (Box 8-1).
elderly, is considered a reversible cause of dementia.
When anxiety symptoms are also present, depression
can manifest as mild delirium (see Chapter 3).
coherently. A confused patient is disoriented to
Delirium, caused by alteration in brain metabolism, is
Dementia, a chronic generalized impairment of
Depression as a cause of confusion, especially in the
usual behavioral patterns and the conditions involved
with this episode.
Is this a condition that requires immediate
intervention?
Key Questions
n How suddenly did the confusion start?
n Is the patient alert and aware of time, person, and
place?
n Has the patient expressed thoughts of suicide (in
words or actions)?
n Does the patient use alcohol or other drugs?
Confusion that is acute in onset and persistent can
indicate delirium, a cerebrovascular event, cerebral
infection, subdural hematoma, or neoplasm. A history
of altered level of consciousness and the patient’s current state indicate a medical condition that requires
immediate intervention. Acute-onset confusion can
produce paranoia and aggression. Suicidal ideation
can accompany depression and is an indication for
immediate intervention and further evaluation. If the
patient has been abusing alcohol or other chemical
substances, acute withdrawal can require immediate
medical intervention.
If the onset is gradual and the patient is not seri-
ously ill, consider depression or dementia. Remember
that depression and dementia can coexist. Unless the
patient is suicidal or seriously ill, both depression and
dementia can be handled in a more temperate manner.
What distinguishing characteristics
of confusion does this patient exhibit?
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Obtaining an appropriate history from a confused patient involves the use of another person as the historian. Preferably that person is someone who has had
consistent contact with the patient and can report about
98
Key Questions
n Was the onset of the confusion abrupt (i.e., over a
period of minutes or hours) or gradual (i.e., a few
days, weeks, or months)?
n Does the confusion change within a 24-hour period
(stable or uctuating)?
Chapter 8 • Confusion in Older Adults 99
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Box 8-1
Reversible Causes of Dementia
D Drugs/medications
E Emotional illness/depression
M Metabolic/endocrine disorders
E Eye/ear involvement/environmental
N Nutritional/neurological
T Tumors/trauma
I Infection
A Alcoholism/anemia/atherosclerosis
Modifiable Causes of Dementia
• Normal pressure hydrocephalus
• Hepatic encephalopathy
• HIV encephalopathy (AIDS dementia complex)
Irreversible Causes of Dementia
• Alzheimer disease
• Multi-infarct dementia
• Huntington chorea
n Is there a change in the sleep pattern?
n Is the patient alert and aware?
n Has the patient experienced seeing, hearing, or feeling
Causes of Dementia
things that are not there?
n Is there any history of head trauma?
Onset and Duration
Confusion that is abrupt in onset but short-lived can
indicate a transient ischemic attack (TIA). Sudden
onset, usually over a period of hours, is characteristic
of delirium. In delirium, the condition is persistent but
has been present for no longer than 1 month. In an
acute confusional episode, the symptoms are less
severe than with delirium with a less sudden onset. The
onset in depression is usually gradual, over a period of
weeks, and is persistent over time. In dementia, the
onset is insidious and gradual; the condition has often
been present for many weeks or months.
insomnia and is drowsy and tired during the day. Thus
the sleep/wake cycle is usually fragmented, and the
patient tends to be restless and agitated and has hallucinations while awake during the night.
Level of Consciousness
In both dementia and depression, the individual is likely
to be both alert and aware, although the mood can be
depressed. With delirium, the patient will have a
decreased level of consciousness, be less alert and
aware, and can be difcult to arouse. With an acute
confusional state, the person will demonstrate impaired
concentration and make errors in thinking.
Hallucinations
Visual, tactile, and auditory hallucinations are common
with delirium, especially at night when changes in
environment or activity occur. Hallucinations are uncommon in both depression and dementia, although
hallucinations can occur in late-stage dementia.
Head Trauma
Head trauma can produce confusion and disorientation.
In older adults, common causes of head trauma include
motor vehicle crashes, physical abuse, and falls.
Are there any associated symptoms
that will point me in the right direction?
Key Questions
n Has the patient shown any tremor, especially at rest?
n Has the patient had any trouble walking?
n Has the patient reported severe headache and/or
nausea?
n Has the patient had a fever?
n Has the patient gained or lost weight?
n Does the patient engage in his/her usual activities?
Fluctuation in Symptoms
With delirium, the symptoms can uctuate over the
course of a day and frequently are worse at night and
with fatigue. The course is more stable with both
depression and dementia, with little variation over a
24-hour period.
Disturbance in Sleep/Wake Cycle
The sleep/wake cycle in delirium is always impaired.
Either the wakefulness is abnormally increased and the
patient gets little or no sleep, or the patient has night
Tremor and Gait Disturbance
Tremors are associated with parkinsonism, human
immunodeciency virus (HIV) encephalopathy, and
liver disease. Gait disorder is associated with parkinsonism, medication reactions, and head trauma.
Headache, Nausea, and Fever
Headache and nausea are associated with head trauma,
stroke, and tumor. Fever is usually present with HIV
infection, other systemic infections, or acute alcohol
withdrawal.
100 Chapter 8 • Confusion in Older Adults
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Change in Weight and Usual Activities
Patients with depression can exhibit vegetative symptoms (e.g., cessation of talking, eating, dressing, and
toileting; insomnia; weight loss or gain; diminished
interest in most activities or former pleasures) and feelings of worthlessness.
What does the pattern of cognitive losses tell me?
Key Questions
n What specic problems with mental abilities or
thinking have you noticed?
n What behavioral changes or personality changes
have you noticed?
Changes in Mental Abilities and Behaviors
Patients with delirium have global cognitive losses that
involve memory, thinking, perception, and judgment.
These patients can become completely disoriented,
irritable, and fearful. They can be difcult to arouse or
conversely have insomnia. Families sometimes note
visual hallucinations.
Patients in an acute confusional state can be
disoriented—especially for time, less for place, and
almost never for self. They show impaired concentration, experience sensory misperceptions, and make
errors in thinking.
Dementia, particularly early in the disorder, presents with more selective cognitive losses. Family
members report that patients cannot remember recent
events, are disoriented, are irritable or depressed, have
poor hygiene, show poor judgment, make nancial
errors, are socially withdrawn, have difculty nding
or saying the right words, are clumsy or fall, have
urinary incontinence, have deteriorating interpersonal
relationships, and show personality changes.
Fewer cognitive losses occur with depression. These
persons can exhibit cognitive losses consistent with
confusion—apathy and drowsiness, impaired concentration, and errors in thinking. The most common cognitive
symptoms are severe negative thinking, guilt, and remorse.
Is the confusion caused by a concurrent
health problem?
n Has the patient been acutely ill recently?
n Is there a history of mental illness or similar thought
disturbance?
Current and Past Health Status
Obtain past medical records to make a complete medical
history. Most likely you will have to use a relative or close
friend to determine current and past health status. Many
systemic conditions and disorders can produce alteration
in mental status, particularly in older patients (Box 8-2).
Chronic health problems (such as alcoholism, renal failure, liver disease, severe anemia, chronic obstructive
pulmonary disease [COPD], severe cardiovascular disease, and HIV) predispose individuals, especially the
elderly, to the development of confusion. Patients with
multiple chronic health problems are particularly at risk.
Could the confusion be caused by medication?
Key Questions
n What medications is the patient taking?
n Is the patient taking the medications correctly?
Medications
Drugs that can produce altered mental status include
the following:
n Alcohol
n Antibiotics (e.g., isoniazid, aminoglycosides)
n Anticholinergic agents
n Anticonvulsants
n Antidepressants
n Antihypertensive agents (e.g., reserpine, ß-blockers,
methyldopa, clonidine, hydralazine)
n Antiparkinsonian agents
n Cardiac drugs (e.g., digitalis, lidocaine, ß-blockers,
vasodilators, diuretics)
n Chemotherapeutic agents (e.g., methotrexate)
n Gastrointestinal drugs (e.g., H
pramide)
n Illicit drugs (e.g., amphetamines, cocaine, opiates)
n Narcotics
n Over-the-counter cold/allergy preparations
n Sedatives
n Tranquilizers
blockers, metoclo-
2
Key Questions
n Does the patient have any chronic health conditions?
n Has the patient been hospitalized recently, and if so,
for what reason?
Taking Medication Correctly
Combinations of these medications increase the probability of medication-induced confusion. People who
are confused may be taking medications improperly,
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