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Chapter 7 • Breast Pain
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79
This results in sparse facial, body, pubic, and axillary
hair; a high-pitched voice; a female type of fat distribu-
20 times higher than that of males without Klinefelter
syndrome.
tion and small testes and penis. By late puberty, 30% to
50% of boys with Klinefelter syndrome manifest gynecomastia, which is secondary to elevated estradiol
levels, and increased estradiol/testosterone ratio.
The risk of developing breast carcinoma is at least
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Cyclic mastalgia Corresponds to changes in
Noncyclic mastalgia Women age 40-50 yr
Mastitis/abscess
Inflammatory breast cancer Sensations of heaviness, burning,
Mammary duct ectasia Menopausal women
Pregnancy Missed period; contraceptive use
Costochondritis
Herpes zoster Pain; history of chicken pox Vesicular eruption along a
Klinefelter syndrome Adolescent boy with
Common Causes of Breast Pain
menstrual cycle
Bilateral; pain often greatest in
upper, outer breast quadrant
Dull, heavy, and aching pain;
radiates to axilla and arm;
varying duration
No relationship to menses
Pain localized to specific area in
breast; described as sharp,
stabbing, burning, throbbing
Sudden onset of swelling,
tenderness, erythema,
and heat, which is usually
accompanied by chills, fever,
and increased pulse rate
Lactating women after milk is
established, usually second to
third week after delivery
or tenderness in the breast;
rapid increase in breast size; or
a nipple that is inverted (facing
inward).
Bilateral or unilateral pain,
tenderness; periods of
inflammation; nipple
discharge
failure
Pain in area of sternum
and ribs; pain with deep
inspiration
Breast Lumps/Nipple Discharge Associated
With Breast Pain
See Chapter 6 for a discussion of breast lumps and
nipple discharge.
Often no physical findings;
breasts can be tender
Often no physical findings;
breast can be more nodular; lump can be present
Swelling, redness, tenderness
Possible abscess formation
with hardened mass, area
of fluctuation, erythema,
and heat
Underlying pus-filled
abscess can impart bluish
tinge to skin
Swelling, redness that covers
more than a third of the
breast, tenderness; peau
d’orange
Often no physical findings
Nipple retraction can occur;
lump may be present
Breast tenderness and
swelling
Tenderness on palpation,
when moving rib cage, or
when taking a deep
breath
cutaneous dermatome
Testes prepubertal,
None; history and
clinical
examination
Mammogram;
ultrasound
None; clinical
examination
Mammogram;
ultrasound; biopsy
Mammogram;
ultrasound
Urine or serum for
b-hCG
None; trial of NSAIDs
None
Karyotyping
Breast lumps associated
with breast pain
b-hCG, Human chorionic gonadotropin; NSAIDs, nonsteroidal antiinflammatory drugs.
enlargement
See Chapter 6 for discussion on breast lumps and nipple discharge.
body hair
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Chapter 7 • Breast Pain
References and Readings
Amory JK, Anawalt BD, Paulsen CA, Bremner WJ: Klinefelter’s
syndrome, Lancet 356:333, 2000.
Brown N, White J, Brasher A, Scurr J: The experience of breast pain
(mastalgia) in female runners of the 2012 London Marathon and
its effect on exercise behaviour, Br J Sports Med 48:320, 2014.
Duijm LE, Guit GL, Hendriks JH, et al: Value of breast imaging in
women with painful breasts: Observational follow up study, BMJ
317:1492, 1998.
Hamed H, Fentiman IS: Benign breast disease, Int J Clin Pract
55:461, 2001.
Leddy R, Irshad A, Zerwas E, et al: Role of breast ultrasound and
mammography in evaluating patients presenting with focal breast
pain in the absence of a palpable lump, Breast J 19:582, 2013.
Lumachi F, Ermani M, Brandes AA, et al: Breast complaints and risk
of breast cancer: Population-based study of 2,879 self-selected
women and long-term follow-up, Biomed Pharmacother 56:88,
2002.
Morrow M: The evaluation of common breast problems, Am Fam
Physician 61:2371, 2000.
Padden DL: Mastalgia: Evaluation and management, Nurse Pract
Forum 11:213, 2000.
Santen R, Mansel R: Benign breast disorders, N Engl J Med 353:275,
2005.
Smith RL, Pruthi S, Fitzpatrick LA: Evaluation and management of
breast pain, Mayo Clin Proc 79:353, 2004.
Templeman C, Hertweck SP: Breast disorders in the pediatric and
adolescent patient, Obstet Gynecol Clin North Am 27:19, 2000.
Tumyan L, Hoyt A, Bassett L: Negative predictive value of sonogra-
phy and mammography in patients with focal breast pain, Breast J
11:333, 2005.
Wright WL: Diagnosis and treatment of herpes zoster: Role of the
nurse practitioner, J Am Acad Nurse Pract 15:10, 2003.
CHAPTER
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8
he rst step in the evaluation of a patient with
T
chest pain is to determine whether the pain is a
life-threatening condition. Acute coronary syndrome
includes myocardial ischemia and myocardial infarction (MI), aortic dissection, pulmonary embolism (PE),
or pneumothorax. These are life-threatening causes of
chest pain and must be assessed rapidly so emergent
treatment can be initiated. A quick diagnosis of acute
MI greatly increases the patient’s chances of survival.
Aortic dissection is a rare but catastrophic cause of
chest pain. Pulmonary embolism is accompanied by
the sudden onset of dyspnea.
If acute ischemic heart disease is an unlikely cause,
other causes of acute chest pain should be considered,
such as pulmonary, gastrointestinal (GI), psychological, musculoskeletal, or other conditions (such as pericarditis). A signicant proportion of patients whose
presenting symptoms include acute chest pain have
esophageal spasm, or gastroesophageal reux disease
(GERD); however, harmless conditions can mimic
more serious disease. Pericarditis and valvular diseases, such as aortic stenosis and mitral valve prolapse,
are less emergent causes of cardiac pain.
Pain in any organ or system can be the result
of inammation, obstruction/restriction, or distention/
dilation. All pain arising from the GI, musculoskeletal,
respiratory, cardiac, and pulmonary systems transmits
to the same spinal cord segments—T1 through T5—
and makes identication of the specic origin of discomfort difcult. Many causes of noncardiac chest
pain relate to chest anatomy, specically skin, muscles,
ribs, cartilage, pleura, lungs, esophagus, mediastinum,
and thoracic vertebrae.
In an infant, sweat on the forehead can indicate
congenital heart disease (CHD). A decrease in cardiac
output causes a compensatory sympathetic overactivity, resulting in a cold sweat on the forehead.
In children, chest pain is rarely associated with serious organic disease. The most common causes of chest
pain in children are costochondritis, trauma, muscle
strain to the chest wall, and respiratory conditions
Chest Pain
associated with cough. Chest pain from rheumatic
heart disease or other cardiac disease is relatively rare
in children. However, patients and families often associate chest pain with heart disease and can be anxious about the condition because of reports of sudden
death in young athletes.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
The identication of potentially acute, life-threatening
situations must be made immediately. After you have
determined that there is no immediate risk of severe
oxygen deprivation to vital organs (e.g., MI, aortic dissection, and PE), proceed with a focused history.
First, is this a life-threatening condition?
Key Questions
l
Can you describe the pain? What does it feel like?
(Dull, sore, stabbing, burning, squeezing?)
l
Does the pain radiate?
l
When did it start?
l
What were you doing when it started?
l
How long have you had the pain?
l
What other symptoms have you noticed?
Characteristics of Pain
Typical anginal pain is described as substernal heaviness, pressure, or a squeezing sensation that is provoked
by exertion and relieved with rest or nitroglycerin. The
substernal pain or discomfort radiates to the left shoulder and down the left arm, and can extend to the neck
and lower jaw. An abrupt tearing pain, located in the
anterior or posterior chest, characterizes aortic dissection. This pain can migrate to the arms, abdomen, back,
or legs. Patients with Marfan syndrome are at risk for
aortic dissection.
Pneumonia, PE, and pneumothorax present with
chest pain. The patient with PE is able to point to
the area of pain over the affected lung and usually
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Chapter 8 • Chest Pain
describes a gripping, stabbing pain that is moderate to
severe in intensity. The pain can radiate to the neck or
shoulders. Patients experiencing a pneumothorax most
frequently report mild to severe chest pain of sudden
onset, located in the lateral thorax, and radiating to the
ipsilateral shoulder. The quality of pain is described as
sharp or tearing. Chest pain of pneumonia is located
over the area of inltration and does not radiate. It
frequently has a burning or stabbing quality, and is associated with cough (see Chapter 11).
Remember that chest pain is subjective and that
prior experience, personal attitudes, and cultural values
form the patient’s perception of pain. Assessment of
the intensity of the pain is done using a 0 to 10 analog
scale, with 0 being no pain and 10 being the worst pain
ever experienced.
Onset of Pain
Determine if the onset of pain was sudden or gradual,
and what the patient’s activity was at the time of
onset. The typical onset of angina occurs during exercise, exertion, or emotional stress and is relieved
by rest or nitroglycerin. Chest pain of MI can occur
at any time and is relieved by rest in 2 to 5 minutes.
Sudden onset of chest pain and dyspnea is common
with PE. In a pneumothorax, the patient usually
reports a sudden onset of severe coughing, exertion,
or straining that precipitated the chest pain. Chest
pain caused by pneumonia occurs gradually over
several hours or days. Chest pain in adolescents
that occurs after activity can indicate organic cardiac
disease.
Most MIs occur in the morning hours, with a peak
on Mondays. Patients might also report acute chest
pain hours after heavy exertion, such as snow shoveling, sexual intercourse, or other physical activity.
In children, ask about recent choking episodes or
swallowing a foreign body if the pain increases with
attempts to swallow. Pain that usually occurs when
lying down after eating is associated with GERD. Trauma
to the chest wall from a fall or strenuous activity can
cause rib fractures or chest contusions.
activity, as compared to stable angina pain, which lasts
2 to 5 minutes and is relieved with rest.
Associated Symptoms
The person experiencing an acute MI frequently reports
nausea, vomiting, diaphoresis, shortness of breath, and
syncope. Pulmonary embolus is often associated with
shortness of breath, apprehension, hemoptysis, and
chest pain that increases with deep breathing. Fever,
cough, and thick sputum production usually accompany
chest pain caused by pneumonia.
Does the patient have risk factors for coronary artery
disease?
Key Questions
l
How old are you?
l
Do you smoke?
l
Do you have high blood pressure, diabetes, or heart
disease?
l
Do you have a history of myocardial infarction?
l
Has anyone in your family had a heart attack, or
stroke before the age of 60?
Risk Factors
According to the report of the U.S. Preventive Services
Task Force, clinically signicant coronary artery disease
(CAD) is uncommon in men under 40 and premenopausal women, but risk increases with advancing age.
The presence of risk factors, such as smoking, hypertension, diabetes, high cholesterol level, obesity, and family
history of heart disease increase the risk of CAD. The
National Cholesterol Education Program identies the
following major risk factors for CAD: cigarette smoking, hypertension, low high-density lipoprotein (HDL)
cholesterol level (less than 40 mg/dL), a family history
of premature coronary heart disease, age (men 45 years
and older; women 55 years and older), and diabetes. In
addition, a fasting lipoprotein panel should be obtained
that includes low-density lipoprotein (LDL) (less than
100 mg/dL is optimal), and total cholesterol values (less
than 200 mg/dL is desirable).
Duration
The most life-threatening conditions produce an acute
onset of chest pain. The more chronic the pain, the less
likely it is that a specic cause will be found. Intermittent chest pain that occurs frequently probably indicates a more serious problem, such as angina, than one
episode of brief, mild pain. Unstable angina is a persistent
chest pain, lasting about 30 minutes, not related to
If this is not a life-threatening condition, what does
a description of the pain tell me?
Key Questions
l
Is the pain acute or chronic?
l
What were you doing when the pain rst occurred?
l
Point to where the pain is located. Does it spread to
any other part of your body?
l
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What seems to trigger the pain?
l
Does the pain awaken you from sleep?
Acute or Chronic
After life-threatening causes of acute chest pain are ruled
out, sudden-onset pain can be associated with trauma,
musculoskeletal injury, or inammation. Chronic, gradual-
onset chest pain is rarely an emergent situation. Chest
pain can be the sequel to an upper respiratory tract infec-
tion. Pain from GERD often occurs at night or after a
large meal.
Location and Character of Pain
Pain arising from the thoracic skin and other super-
cial tissues, such as that associated with furuncles,
contusions, and abrasions, is sharply localized.
Irritation of the intercostal nerves can result in a
neuritis that produces sudden onset of a stabbing, burning pain and tenderness. The pain is easy to locate at
the intercostal spaces and along inamed nerves with
three maximal pain points: adjacent to the vertebrae, in
the axillary lines, and along the parasternal lines. Pain
can be severe when the patient breathes deeply, coughs,
or moves suddenly.
Dorsal root irritation associated with herpes zoster
can present with intense burning or knifelike pain along
the spine to the lateral thoracic wall and the anterior
midline. This pain can restrict movement of the trunk
and respirations. Generally this pain is continuous and
increases in severity.
Nerve root pain is caused by mechanical irritation
or edema of the nerve root. This pain can be felt at the
point of irritation, but is frequently referred to points
along the peripheral course of the nerve. Thoracic spinal segment root pain is often referred to the lateral and
anterior chest wall, and is seen with spinal diseases and
thoracic deformities.
Costal cartilage that loosens from the brous attachment most often causes localized, dulling, aching pain,
and tenderness over the eighth, ninth, and tenth ribs on
either side; however, the pain can be acute, paroxysmal, or stabbing.
Musculoskeletal pain is produced by irritation of
tissues and transmitted through the sensory nerves. The
stimulus travels through the nerve to the dorsal ganglion and up the spinal afferent pathway to the central
nervous system.
Bone pain results from irritation of sensory nerve
endings in the periosteum, is intense, and well localized.
Chronic diseases affecting the bone marrow can cause
a poorly localized pain of varying severity. Ribs are
Chapter 8 • Chest Pain
83
common sites for metastatic malignant deposits, probably because of their rich vascularity. Metastasis to the
rib and the periosteum results in pain. Referred pain
from a dermatome is described as intense, aching, and
boring.
When tumors involve the mediastinum, chronic
aching or dull substernal chest pain is produced by
pressure of the tumor against the spine or ribs.
Bronchial pain is caused by the involvement of
adjacent structures. The trachea and large bronchus
are innervated by the vagus nerve (cranial nerve X).
The ner bronchi and lung parenchyma are free of
pain innervation, therefore extensive disease can
occur in the periphery of the lungs without pain until
the process extends to the parietal pleura. Pleural
pain, or pleuritis, results from the loss of normal
lubricating function, and irritation of the serous membranes of the pleural surfaces. The pain waxes and
wanes with respirations, movement, and cough. Diaphragmatic pleural pain can be referred to the base of
the neck or abdomen. Children often report chest pain
from tachyarrhythmia because they are unable to differentiate between true pain and the discomfort of the
arrhythmia. Cardiac causes of chest pain in children
are usually associated with congenital anomalies
or acquired diseases of the coronary artery, such as
Kawasaki disease.
Sleep
Distinguish between awakening with pain and awakening from pain. Awakening because of pain signals a
more serious problem of organic origin, such as cardiac ischemia. Psychogenic chest pain in adolescents
commonly accompanies sleep disturbances.
What do associated symptoms tell me?
Key Questions
l
Do you have a cough or a change in your usual
cough?
l
Do you bring up sputum? If so, how much and what
color?
l
Do you have a fever?
l
Are you lightheaded or dizzy?
l
Do you feel like your heart is racing?
Cough and Sputum Production
Chest pain associated with cough and colored sputum
production is usually caused by an acute infection,
such as pneumonia. Pain results from a pleural effusion, or the collection of uid in the pleural space.
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Chapter 8 • Chest Pain
Sputum associated with pneumonia can be dark green,
rust color, or red. Frequent lower respiratory tract
infections can be caused by congenital heart disease,
with large left-to-right shunts, and an increase in pulmonary blood ow. Children and older adults, with
persistent cough, can experience chest pain related to the
musculoskeletal strain associated with coughing. People
with asthma can develop chest pain from straining of the
chest wall muscles caused by tachypnea, coughing, or
retraction.
Fever
Fever can indicate pneumonia, myocarditis, pericarditis, or PE. It is possible that elderly and immunosuppressed people will not have fever, even with
bacterial infections.
Lightheadedness, Dizziness, or Fainting
Arrhythmias caused by hypoxia, trauma, or electrical
shock can cause insufcient coronary blood ow and
chest pain. Paroxysmal atrial tachycardia (PAT) can
cause lightheadedness. Diastole is shortened in PAT,
and thus cardiac output is decreased. Most cases of
syncope in adults are caused by cardiac problems such
as structural heart disease, arrhythmias, and coronary
insufciency. Most cases of syncope in children
are benign and are the result of breath holding, orthostatic syncope, hyperventilation, or vasovagal syncopal
episodes.
Palpitations
Caffeine, stress, and hormonal changes can cause the
sensation of a rapid or forceful heartbeat. Mitral valve
prolapse can present with a history of palpitations.
Theophylline, levothyroxine and b-adrenergic agents
can cause arrhythmias such as supraventricular tachycardia, which can be perceived as palpitations.
Rib fractures, musculoskeletal strains, and contusions
can cause signicant chest pain, especially with movement. Musculoskeletal disorders are the most common
cause of chest pain in children and younger adults.
Decreased exercise tolerance can result from sig-
nicant heart disease such as shunts, arrhythmias, or
CAD. In children, congenital coronary anomalies can
arise abnormally (as from the pulmonary artery), take
an abnormal course, or have stula connections to
other structures, resulting in exertional chest pain.
Any episode of moderate to severe chest pain during
or after exercise should be investigated as cardiac in
origin.
History of Chest Trauma
A careful history of preceding activities should be
obtained to detect any recent muscle strain. Posttraumatic pericardial effusion can develop 1 to 3 months
after chest trauma. Blunt injury can cause hemothorax,
pneumothorax, soft tissue injury, and rib fracture. A
ruptured spleen can cause irritation of the phrenic
nerve, producing shoulder pain.
Pain With Movement
Pain of cardiac origin, except for pericarditis, is not
affected by respiration. Pain on inspiration suggests
pleural etiology. A sharp, pleuritic pain, relieved by
sitting upright and leaning forward, suggests pericarditis. Pain that is aggravated by chest wall movement,
especially along the sternal border, is most frequently
costochondritis; both adults and children can experience this inammatory condition of the costal cartilage. Lying at, consuming alcohol, taking aspirin,
eating spicy meals, and wearing tight clothing often
precipitate the pain of esophagitis. Frequently, patients
report that this pain occurs after lying down following
eating a meal.
Is the pattern of pain related to activity and position
change?
Key Questions
l
Can you describe your recent physical activities?
l
Have you had any injury to the chest?
l
Does chest movement or position make the pain better
or worse?
Recent Activities
Recent strenuous exercise (especially weight lifting)
or horseplay can strain the pectoral, trapezius, latissimus dorsi, serratus anterior, and shoulder muscles.
Is there a gastrointestinal origin for the patient’s
chest pain?
Key Questions
l
Does the pain get better or worse from eating?
l
Do you have blood in your stools?
l
Have you vomited any blood?
Food Association
Differentiating between esophageal and cardiac origin
of chest pain can present a challenge because the
character and location of the pain can be very similar.
Nitroglycerin can relieve both the pain of angina and
Chapter 8 • Chest Pain
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85
the pain of esophagitis. In these instances, an electrocardiogram is indicated.
Esophagitis, usually as a result of gastroesophageal
reux (GERD), is the most frequent GI cause of chest
pain. Patients describe this pain as “heartburn,” or a
dull, burning sensation in the epigastric and retrosternal area. The esophagus is more pain sensitive in its
proximal portion. Therefore chest pain that is temporally related to eating meals or particular foods should
suggest esophagitis.
Sometimes associated symptoms of a sour taste
in the mouth and mild nausea are associated with
esophagitis. An esophageal tear or spasm causes more
acute, severe chest pain, described as a “tearing” or
“crushing” sensation. Frequently the patient experiencing pain of GI origin reports mild to moderate
chest pain occurring intermittently over days to
months.
Peptic ulcer and cholecystitis can cause chest pain.
Hematemesis (blood in the emesis) or hematochezia
(blood in the stool) frequently accompanies peptic ulceration. Cholecystitis is frequently reported as right
anterior chest pain that radiates to the shoulder or
upper back.
Acute pancreatitis should be considered if the chest
pain is severe and constant and is reported in the epigastric area of the abdomen, radiating to the chest,
shoulder, and arm. Pancreatitis is often accompanied
by hypotension. Physical examination and diagnostic
tests are necessary to differentiate it from chest pain of
cardiovascular origin.
cervical and thoracic spine and shoulders can produce
upper chest pain. This pain is aggravated by range of
motion of the affected joints.
Sickle cell disease (SCD) can cause chest pain. In
sickle cell anemia, the erythrocytes become rigid and
“sickle,” leading to capillary occlusion and sickle cell
crisis. The heart increases the stroke volume to compensate for the anemia. The heart gradually dilates and
heart failure ensues. Chest pain in a patient with SCD
can also originate from acute coronary syndrome
(ACS). In this condition, chest pain, fever, dyspnea,
and cough are caused by infarction of lung tissue or an
infectious agent.
Marfan syndrome is a hereditary connective tissue
disease. Cardiovascular involvement occurs in more
than 50% of people by age 21. Mitral valve involvement is common, with auscultatory ndings of mitral
regurgitation and mitral valve prolapse. Marfan syndrome is associated with an increased risk of aortic
dissection.
Kawasaki disease often has a long-term complication of CAD, coronary occlusion, or MI.
What does the family history tell me?
Key Questions
l
Has anyone in your family had heart disease, chest
pain, or sudden death from cardiac arrest?
l
Was anyone in your family born with heart
problems?
l
Does anyone in your family have high cholesterol?
Could this pain be from a systemic cause?
Key Questions
l
Do you have any skin problems?
l
Do you have any chronic health problems?
Skin Symptoms
If the patient reports persistent unilateral chest pain of
pruritic, burning, or stabbing quality, consider herpes
zoster. This pain will follow the distribution of a cervical
or thoracic nerve root. A vesicular rash in the area of
pain is characteristic; this rash occurs several days
after the occurrence of chest pain.
Systemic Conditions
Chest muscle pain can be caused by localized inammation of the muscles in collagen diseases, such as
polymyositis, bromyalgia, or systemic lupus erythematosus. Arthritic inammatory changes of the
Family History
History of congenital heart disease in close relatives
increases the chances of its occurrence in a child.
When one child has the condition, the risk of siblings
having the condition increases by one-third. Essential
hypertension and CAD show a strong family pattern.
Hypertrophic cardiomyopathy has a positive family
history, with autosomal dominant transmission in onethird of patients.
Children who have a homogenous family history of
hypercholesterolemia can present with CAD before the
age of 20.
What is the emotional state of the patient?
Key Questions
l
In the past 6 months, have you had a spell or an attack
in which you suddenly felt frightened, anxious, or
very uneasy?
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l
In the past 6 months, have you had a spell or an attack
Chapter 8 • Chest Pain
in which for no apparent reason your heart suddenly
began to race, you felt faint, or you could not catch
your breath?
Panic Disorder
A response of “yes” to the above key questions can be
a highly sensitive screen for a psychogenic component
of pain, and is a positive screen for panic disorder.
Patients with anxiety or depression often describe
feelings of chest heaviness or tightness that can last
for days, and dyspnea unrelated to exertion or rest.
Patients can also report difculty taking a deep
breath.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
A focused physical examination of the patient experiencing chest pain will provide objective data for the
assessment. A thorough examination of the cardiovascular, pulmonary, upper GI, dermatologic, and upper
body musculoskeletal systems is essential. The electrocardiogram (ECG) greatly improves the accuracy of
the diagnosis of acute chest pain and should be
obtained early in the assessment if cardiac causes are
suspected.
Observe General Appearance
Initial observation of the patient will provide clues to
the severity of the problem. Observe for grimacing,
diaphoresis, pallor, cyanosis, tachypnea, use of accessory muscles for breathing, splinting of chest
wall, and unequal chest wall excursion. People experiencing an MI can be diaphoretic, pale, and anxious.
Patients manifesting PE appear diaphoretic and anxious; respirations are rapid; splinting of the chest is
common; and peripheral cyanosis can be present.
People with fractured ribs or signicant chest wall
contusions splint their chest wall, and take shallow
breaths to avoid aggravating pain with respiratory
expansion.
Observe the height and weight of a child. Abnormal
ndings for age can indicate chronic disease.
Measure Vital Signs and Note Respiratory Patterns
Vital signs for people experiencing angina can be
within normal ranges. Frequently, however, with acute
MI, blood pressure is elevated and cardiac arrhythmias are present. Hypotension can indicate cardiogenic
shock.
The patient with aortic dissection can be hypoten-
sive with unequal peripheral pulses. Pericarditis can be
accompanied by fever, rapid and shallow respirations,
and hypertension. Myocarditis can present with fever,
respiratory distress, and paradoxical pulse.
In heart failure, decreased stroke volume reduces
the systolic blood pressure, and compensatory vasoconstriction maintains a constant diastolic pressure.
This can result in a decreased pulse pressure.
Pneumothorax is manifested by tachypnea and un-
equal chest wall excursion. The patient with pneumonia can also be tachypneic, with signs of infection that
include fever and a productive cough.
In children, chest pain with tachycardia and hypoten-
sion is generally caused by hypovolemia, secondary to
a hemothorax, hemopneumothorax, or vascular injury.
Pain can also be caused by rhythm disturbance.
The rate, rhythm, and depth of respirations in patients
experiencing costochondritis, GI disease, or herpes zoster
are not usually altered.
Hyperventilation can cause chest pain as a result
of hypercapnic alkalosis or coronary artery vasoconstriction. Most hyperventilation is associated with a
stressful event or emotional upset; however, aspirin
overdose, severe pain, and diabetic ketoacidosis can be
organic causes.
Inspect the Skin
Cool, pale, moist skin can accompany an acute MI, PE,
or aortic dissection. Observe the skin overlying the
area of chest pain for signs of the vesicular rash of
herpes zoster. Petechial rash on the face and shoulders
can be a sign of protracted coughing as a result of
pneumonia, asthma, or upper respiratory tract infection. Bruises can indicate trauma or abuse.
Palpate Trachea and Chest
Tracheal shift can occur with pneumothorax and in
children with atelectasis, involving a signicant portion of one lung. To assess the trachea for lateral displacement, position your index nger rst on the right
side of the suprasternal notch, and then the left. If the
trachea has shifted to the side, you will feel the wall on
one side but only soft tissue on the other. In a pneumothorax, the trachea is deviated to the opposite side
during exhalation and toward the side of the pneumothorax during inspiration. The trachea is displaced
toward a lung that is atelectatic, with the displacement
exaggerated during inspiration.
Palpate the entire chest wall for tenderness, depres-
sions, or bulges. Fractured ribs and contusions will
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result in tenderness to palpation and possible deformity. Palpate each costochondral and chondrosternal
junction. Costochondritis will be manifested by pain
with palpation over the cartilage between the sternum
and the ribs. Palpation and range of joint motion can
elicit arthritic pain in the shoulder or cervical spine.
Musculoskeletal chest pain is usually reproduced with
palpation or by moving the arms and chest through a
variety of positions. Subcutaneous emphysema may be
palpable at the neck or upper chest wall. Rib pain on
palpation in children without a reported history of
trauma can indicate child abuse.
To check the chest wall for symmetry, rst test for
diaphragmatic expansion of both the anterior and the
posterior thorax between the eighth and tenth ribs. As
the patient takes a deep breath, the practitioner places
each hand over the chest with thumbs inward. Each
thumb should move the same distance from the spine
or costal margins. Pneumothorax, pneumonia, and fractured ribs can alter this nding.
Percuss the Chest
Percussion in the area of pneumothorax will result in a
hyperresonant sound of an air-lled cavity. Areas of
inltration, as in pneumonia, will produce a dull or at
sound.
Auscultate Breath Sounds
Instruct the patient to breathe through the mouth
slowly and deeply. Auscultate systematically from the
lung apexes to the lower lobes anteriorly, posteriorly,
and laterally (Table 8-1).
Auscultation of bronchial or bronchovesicular
breath sounds over the peripheral lungs can indicate
consolidation. If breath sounds are diminished over
all lung elds, suspect chronic obstructive pulmonary
disease (COPD). Obese patients can have breath
sounds that are difcult to auscultate. Breath sounds
will be inaudible in areas of pneumothorax.
Auscultate for Adventitious Sounds
Adventitious lung sounds are superimposed on normal
sounds and can be auscultated over any area of the lung
eld during inspiration or expiration. Documentation
of abnormal lung sounds should include the type
of sound heard, location, and changes during both
inspiration and expiration phases of respiration.
Crackles or rales are discontinuous popping sounds
heard most often during inspiration. Any disease process
that increases peripheral airway resistance, obstructs the
peripheral airway, or causes a loss of elastic recoil will
produce crackles. These indicate the presence of uid,
mucus, or pus in the smaller airways. Fine crackles are
soft and high pitched. Medium crackles are louder and
lower pitched. Crackles might be heard over the site
of a PE.
Wheezing is frequently described as a whistling
sound, and can be heard during inspiration, expiration, or both. The sound is high pitched and musical.
Wheezing indicates that there is uid in the large
airways, such as in severe heart failure; more often it
is associated with bronchospasm, as seen in asthma.
Wheezing occurs on exhalation because that is when
small airways collapse. During inhalation, the negative pressure in the chest tends to hold open the airways. However, during exhalation, positive pressure
in the alveoli is conducted from the outside of the
small airways and tends to collapse them. The sound
is usually polyphonic; this means that multiple,
slightly different, high-pitched sounds are heard at
the same time. Most of the causes of wheezing affect
many small airways at the same time; each one collapses at a slightly different time, creating a slightly
different tone. The presence of a single-tone wheeze
suggests a single area of blockage, such as with
a foreign body. A prolonged expiratory phase of
respiration is produced by intrathoracic airway
obstruction associated with lower respiratory tract
involvement.
Table 8-1
BREATH SOUND LOCATION QUALITY INSPIRATION/EXPIRATION RATIO
Bronchial Heard on chest over sternum and on
Bronchovesicular Heard over bronchi at first and second
Vesicular Heard over most of peripheral lung fields Soft, low pitched Inspiration longer than expiration
Normal Breath Sounds
back between scapulae
intercostal spaces anteriorly and
between scapulae posteriorly
Loud, high
pitched
Loud, medium
pitched
Expiration longer than inspiration
Equal inspiratory and expiratory
phases
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Chapter 8 • Chest Pain
Rhonchi are continuous, deep-pitched, coarse breath
sounds usually heard during expiration. They are generated by turbulent air passing through secretions in
large airways. Rhonchi can be present when the patient
has pneumonia.
Pleural friction rub is a grating or squeaking sound
heard in the lateral lung elds during inspiration and
expiration. It indicates that inamed parietal and
visceral pleural linings are rubbing together.
If abnormal lung sounds are detected, additional
auscultation for bronchophony, egophony, and whispered pectoriloquy are indicated (see Chapter 14).
Auscultate Heart Sounds
Auscultate for normal heart sounds in all positions, identifying S1, S2, rate, and rhythm. Identication of myocardial ischemia cannot be reliably performed by physical
examination alone. An ECG must be obtained to assess
electrical conduction and the condition of myocardial
function. Abnormal sounds, such as paradoxical S2 during
pain, are a sign of coronary ischemia. A transient, paradoxical S2 could indicate a transient left ventricular dysfunction, congestive heart failure, or left bundle branch
block. A transient S3 (ventricular gallop) or mitral regurgitation murmur at the apex can occur occasionally with
myocardial ischemia or congestive heart failure. An S4
(atrial gallop) typically indicates a stressed heart, which
can be the result of hypertension, MI, or CAD causing
heart failure. A summation gallop is the result of an S3, S4,
and rapid rate; this can also occur with heart failure.
Abnormal rhythms and heart rates are often heard during
MI. ECGs are necessary to identify the specic rhythm.
Also note any murmurs and their location, grade,
and radiation. Incompetent heart valves produce murmurs and can be the cause of heart failure. In children,
a loud murmur, best audible at the upper right sternal
border, or upper left sternal border with a thrill, can
indicate a congenital heart defect.
Aortic diastolic murmur can be present with a dissecting aorta. In aortic valve stenosis, a harsh ejection
systolic murmur, with radiation to the neck, is heard on
auscultation.
Midsystolic click/late systolic murmur (honk) is
heard with mitral valve prolapse. The patient must be
examined in both the supine and upright positions to
elicit the characteristic sounds.
Observe the Spine for Evidence of Scoliosis
People with scoliosis are at increased risk for pulmonary problems because of structural variations that can
cause compression of intrathoracic contents.
Examine the Abdomen
Auscultate for bowel sounds. Palpate the abdomen for
tenderness and masses. Epigastric pain with palpation
can occur with pancreatitis, esophagitis, or peptic ulcer
disease. Cholelithiasis or cholecystitis can be manifested by pain on palpation in the right upper quadrant.
Pancreatitis can produce epigastric pain radiating to
the back.
Examine the Extremities
Clubbing of the ngers can be an indication of chronic
hypoxia resulting from CHD in children or COPD in
adults. Peripheral cyanosis indicates hypoxia if accompanied by central cyanosis. Consider exposure to a
cold environment, or anxiety, if peripheral cyanosis is
observed. Lower extremity edema is a sign of heart
failure or venous stasis. Note the progression of the
edema or whether there is pitting edema up the leg.
Absent peripheral pulse(s) can be a sign of atherosclerotic vessel disease or dissecting aortic aneurysm.
Compare the quality of the pulses bilaterally.
LABORATORY AND DIAGNOSTIC STUDIES
Diagnostic tests are indicated when cardiovascular,
pulmonary, or GI pathology is the suspected cause of
chest pain. Musculoskeletal and neurological causes of
pain usually do not require diagnostic tests.
Electrocardiogram
An ECG can add objective data to the diagnostic process in evaluating chest pain. ECGs are most valuable
when there is a previous ECG with which to compare
the ndings, or when serial ECGs are obtained. ST segment elevation or depression indicates the presence of
injured myocardium. T wave inversion demonstrates
the presence of ischemia. The appearance of both
strongly supports ischemia but is not diagnostic of
CAD. Arterial spasm, pericarditis, and electrolyte imbalance can also cause these variations from normal. Q
waves are indicative of myocardial muscle loss but are
not diagnostic of CAD.
Evidence of ischemia is not always obvious on an
ECG, even when the patient is reporting anginal pain.
This is crucial to keep in mind as you are evaluating a
patient with chest pain; a normal ECG rules out ischemia in the setting of ongoing chest pain.
Stress Testing
People experiencing intermittent chest pain who have
a normal ECG and are not taking digoxin should have
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