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Chapter 8 • Chest Pain
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89
an exercise stress ECG for diagnostic and prognostic
purposes. Treadmill exercise testing uses a standardized protocol of increasing workload with continuous
ECG recording. Stress tests provide information on
myocardial function determined by blood ow. An
important objective of stress testing is to identify
patients who have a high risk of severe (left main or
three-vessel) CAD. The sensitivity of the test ranges
from 65% to 70%.
Exercise Myocardial Perfusion Imaging
This imaging has greater accuracy than the standard
treadmill test when the resting ECG is abnormal, the
patient is diabetic, or has a history of known CAD.
Because of its higher sensitivity, the test is able to
localize and characterize the extent of myocardial
ischemia and to provide direct measurement of left
ventricular function. This test is more costly than a
treadmill test.
Echocardiography
An echocardiogram is a noninvasive cardiac ultrasound examining the heart that provides information
about the cardiac muscle function, left ventricular ejection fraction, position, size, and movements of the
valves and chambers, as well as the velocity of blood
ow by means of reected ultrasound. This test is used
to determine biologic and prosthetic valve dysfunction
and pericardial effusion, to evaluate velocity and direction of blood ow, to furnish direction for further
diagnostic study, and to monitor patients with cardiac
disease over an extended period.
Computed Tomography Scanning
Computed tomography (CT) scans produce crosssectional images of anatomical structures without superimposing tissues on each other. Aortic dissections
and tumors of the lung and pancreas can be detected
with CT scans. Spiral CT uses a cone shaped x-ray
beam in a helical trajectory to focus on a width of
tissue with high image resolution, revealing more detail
than a traditional CT.
Ventilation-Perfusion Lung Scan
Ventilation-perfusion (V/Q) scanning was the rst line
diagnostic tool for diagnosing PE before spiral CT and
is still an acceptable alternative in select settings. With
PE, the blood supply distal to the embolus is restricted.
V/Q scanning uses a radioactive substance to show
how well oxygen and blood are owing to the lungs.
Perfusion imaging will show poor or no visualization
of the affected area. The ventilation scan demonstrates
movement or lack of movement of air in the lungs. The
perfusion scan demonstrates blood supply to the af-
fected area of the lungs. The V/Q scan is reported as
one of three categories: normal, high probability, and
nondiagnostic.
Pulmonary Angiography
A pulmonary angiogram (arteriogram) is necessary if
an embolectomy is considered. Radiographic contrast
medium is injected into the pulmonary arteries, and the
vasculature is visualized. This test can detect emboli as
small as 3 mm in diameter. The test sensitivity is 98%,
and the specicity is 96%. This test is the gold standard
for diagnosing PE, but it is expensive and carries a
small risk of cardiac arrhythmias, anaphylaxis, and
death.
Radiography
Pneumothorax and pneumonia can be identied by
chest radiography. Pneumothorax reveals evidence of
pleural air, whereas pneumonia is seen on radiographs
as a parenchymal inltrate. Chest radiography, with
suspected PE, is usually nonspecic; it can be normal,
can have an elevated hemidiaphragm, or pulmonary
inltrate can be present. Rib radiographs will conrm
rib fracture.
Cervical and thoracic spine and shoulder radio-
graphs can show degenerative joint changes.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a noninvasive
technique that produces cross-sectional images of
the body through exposure to magnetic energy
sources. It does not involve radiation and is used to
differentiate healthy and diseased body tissues. It is
useful in detecting tumors, infection sites, cardiac
muscle perfusion and function, as well as diseased
vessels.
Abdominal Ultrasound
Abdominal ultrasound is a noninvasive procedure to
visualize solid organs. It is useful in detecting abdomi-
nal aortic aneurysm and dissection, masses, uid col-
lections, and infection. Pancreatitis and gallbladder
disease can be detected with ultrasound.
Bronchoscopy
Bronchoscopy permits visualization of the trachea,
bronchi, and select bronchioles. It is useful to diagnose
tumors, hemorrhage, and trauma; to obtain brushings
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Chapter 8 • Chest Pain
for cytological examinations; and to remove foreign
bodies from the lower respiratory tract.
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.
Esophageal pH
When GERD is suspected, 24-hour esophageal pH
monitoring is performed to document pathological acid
reux.
Cardiac Enzymes
Patients presenting with chest discomfort, consistent
with an acute cardiac event, should have biomarkers of
myocardial injury measured. Current clinical practice
is to measure creatine kinase (CK, or CK-MB), and
cardiac troponin (T or I; cTnT or cTnI), cardiac enzymes when an MI is suspected. CK is released into
the bloodstream 4 to 6 hours after heart cell damage
occurs, and peak blood levels of CK are seen after
24 hours. The patient, who has had an MI, will have a
CK-MB result that is ve or more times the normal
value. Elevated CK levels usually indicate heart muscle damage; however, CK levels can be increased with
damage to other kinds of cells as well.
Troponin is released into the bloodstream 2 to
6 hours after heart cell damage, and blood levels peak
in 12 to 26 hours. Elevated levels of T are regarded as
a more reliable indicator of heart muscle damage than
elevated CK levels. Because T is an “earlier” marker of
cardiac cell damage than CK, it is the preferred marker
today for diagnosing MI. Troponin levels remain elevated for 7 to 10 days after the cardiac event.
D-dimer Assay
The D-dimer assay is a blood test performed in patients
with suspected thrombotic disorders. D-dimers are not
normally present in human blood plasma except when
the coagulation system has been activated. An abnormal result rules out thrombosis; however, a normal
result can indicate thrombosis but does not rule out
other potential causes. Its main use is to exclude
thromboembolic disease where the probability is low.
Arterial Blood Gases
Arterial blood gases (ABGs) are obtained to detect
respiratory alkalosis resulting from hyperventilation,
decreased carbon dioxide pressure (PCO2) and sometimes
decreased oxygen pressure (PO2) (hypoxemia). Hypoxemia often correlates with the extent of the lung
area occluded in a PE. ABGs decrease with heart failure resulting in pulmonary edema.
Activated Partial Thromboplastin Time
and Prothrombin Time
Activated partial thromboplastin time (aPTT) is a
clotting test that screens for coagulation disorders and
is used to monitor the effectiveness of heparin therapy. Prothrombin time (PT) measures a potential defect in stage II of the clotting mechanism, through
analysis of the clotting ability of ve plasma coagulation factors. PTs are commonly ordered to measure
the effects of oral anticoagulant therapies. Ineffective
anticoagulation therapy places the patient at risk for
PE. These tests can also be ordered to search for the
cause of PE.
Serum Amylase and Lipase
Amylase is an enzyme that helps convert starch to
sugar; it is produced in the pancreas, liver, salivary
glands, and fallopian tubes. If there is inammation of
the pancreas or salivary glands, increased levels of
amylase enter the bloodstream. Lipase is the enzyme
responsible for the breakdown of fats to fatty acids and
glycerol. The pancreas is the main source of lipase.
Pancreatic damage results in elevated serum lipase
levels. Therefore determining the levels of serum
amylase and lipase is useful in the diagnosis of pancreatitis. Amylase levels return to normal before lipase
levels.
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.
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 OF
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
Chapter 8 • Chest Pain
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91
myocardial infarction (MI) to facilitate prompt
initiation of treatment to limit infarct size and car-
diac damage. The patient with an acute MI generally
describes a sudden onset of pain at rest. It is a per-
sistent, 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, but
more often to the left. Rest or nitroglycerin does
not relieve the pain. The chest pain is often associ-
ated 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 45 years and older; women 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 isoenzymes will help
conrm or rule out an MI.
Aortic Dissection
The patient often is in a great deal of distress, describing unrelenting chest pain as ripping and tearing, and radiating to the interscapular region, jaw,
neck, or lower back. Hypertension is a risk factor in
70% of cases, and it most commonly affects males
50 to 70 years of age. Physical examination reveals
hypotension or an increased pulse pressure and rapid
or weak pulses if the tear produces bleeding into
and along the wall of the aorta. However, specic
circulatory changes depend on the location of the
dissection. Chest radiography demonstrates a wide
mediastinum with extension of the aortic wall beyond the calcic border. Diagnosis can be made by
aortic angiogram, with CT of the chest and abdomen
using a contrast dye injection to visualize the aorta
and its branches. A transesophageal ultrasound can
also be ordered. Patients with suspect aortic dissection should be immediately referred for emergent
care. Studies have demonstrated in-hospital, witnessed aortic dissection carries a mortality rate of
over 96%.
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 enzymes 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
EVIDENCE-BASED PRACTICE
Although certain signs and symptoms have been identified as
being important in recognizing MI, data from the Framingham study estimate that 25% of infarctions may go unrecognized because of either lack of chest pain or the presence
of atypical symptoms. The main predictive factors of silent
Data from Valensi P, Lorgis L, Cottin Y: Prevalence, incidence, predictive factors and prognosis of silent myocardial infarction: a review of the literature.
Arch Cardiovasc Dis 104:178, 2011.
Recognizing MI
myocardial infarction are age, hypertension, history of cardiovascular disease, and diabetes duration. Silent myocardial
infarction is associated with as poor a prognosis as symptomatic myocardial infarction.
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Chapter 8 • Chest Pain
extremity surgery, recent pregnancy or delivery, obesity, oral contraceptive use, or varicose veins. Physical
ndings include restlessness, tachycardia, 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, spiral CT scan,
ventilation/perfusion scan, 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, conditions such 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, seizures, history
of lightheadedness or loss of consciousness during
exercise, and tall and lanky body type with doublejointedness. 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 findings can
be normal. In contrast, unstable angina pain is intense, lasts as long as 30 minutes, and does not
subside with rest or nitroglycerin. Unstable angina
is an impending emergency.
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. Electrocardiogram
will detect signs of irritation to the heart muscle and
arrhythmia.
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 ECG showing diffuse
ST segment elevation in the early stages. Chest radiography can be normal or show effusion with an increase in
cardiac shadow.
Chapter 8 • Chest Pain
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Aortic Stenosis
Aortic stenosis can cause exertional chest pain. Associated symptoms include fatigue, palpitations, dyspnea on
exertion, dizziness, and syncope. Physical examination
will reveal a loud, harsh crescendo–decrescendo 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, palpitations, dizziness, dyspnea
on exertion, 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, 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. Dullness with percussion is heard
over areas of consolidation. Vocal fremitus is heard.
In addition, physical ndings can include tachycardia, tachypnea, bronchophony, and egophony. Chest
radiography, sputum culture, and ABGs will further
support the diagnosis of pneumonia. Follow-up chest
radiographs are indicated after pneumonia because
lung tumors can be hidden by pneumonia. The very
young and very old may be hospitalized for observation and treatment of pneumonia. Healthy adults are
managed on an outpatient basis.
Mitral Valve Prolapse
Patients with chest pain from mitral valve prolapse report a range of signs and symptoms including arrhythmias, palpitations, fatigue, and anxiety. Patients may
have a history of rheumatic fever. 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, usually 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
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 to relieve angina.
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 reflux
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.
Rheumatic Diseases
Rheumatic diseases, such as rheumatoid arthritis and
ankylosing spondylitis, may cause thoracic pain. In children, lasting joint pain and inammation are common
with rheumatic fever but can also indicate rheumatic
heart disease.
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.
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Chapter 8 • Chest 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
course of herpes zoster progresses, a vesicular rash appears in the area of pain (see Chapter 28).
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 excessive alcohol use. 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 ultrasonog-
raphy 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 and Amphetamines
Cocaine and amphetamines increase the metabolic
requirement of the heart for oxygen and decrease 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 normal.
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
normal except for a pleuritic friction rub in 25% of
cases. The condition lasts from 1 to 14 days.
Precordial Catch Syndrome
Recurrent brief episodes of sudden, sharp 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 children and adolescents, and is
benign in nature.
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DIFFERENTIAL DIAGNOSIS OF
Common Causes of Nonemergent Chest Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Stable angina Substernal chest pressure following
exercise or stress and relieved by
rest or nitroglycerin; nausea, SOB,
Myocarditis Chest pain; history of fever,
Pericarditis
Aortic stenosis Chest pain on exertion, substernal
Mitral
regurgitation
Pneumonia Productive cough of yellow or green
Mitral valve
prolapse
Pleuritis Mild, localized chest pain, worse
Esophagitis Substernal pain worse after eating and
Chest trauma
(rib fracture)
Costochondritis Pain along sternal border, increases
Herpes zoster Unilateral chest pain; painful rash Normal breath sounds; vesicular
Peptic ulcer
disease
Cholecystitis Right upper quadrant abdominal
diaphoresis, sternal chest pressure
dyspnea
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
and anginal in quality; fatigue,
palpitations, DOE, dizziness,
syncope
Exertional chest pain, fatigue,
palpitations, dizziness, DOE,
syncope
or rust sputum, dyspnea,
pleuritic pain
Chest pain, varies in location and
intensity; palpitations; anxiety;
nonexertional pain of short duration; history of Marfan syndrome
with deep breathing; recent URI
lying down; sour taste in mouth
History of injury or trauma; pain
with deep breaths; splinting of
chest wall
with deep breaths; history of exercise, URI, or physical activity
Epigastric pain 1 to 2 hr after eat-
ing, 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
Normal examination; possible
transient S
Heart murmur, friction rub, fever ECG, chest radiograph,
Fever before onset of pain, tachy-
cardia, pericardial friction rub
Radial pulse diminished; narrow
pulse pressure; loud, harsh, crescendo-decrescendo 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 midsystolic
click heard over apex; heard
best while patient is in sitting or
squatting position; thoracoskeletal deformity common in children
Shallow respirations, local tender-
ness, pleural friction rub
Epigastric pain with palpitation Esophageal pH
Shallow respirations; chest wall
pain on palpitation
Pain with palpitation over costo-
chondral joints; normal breath
sounds
rash along dermatome
Tenderness to palpitation in
epigastric area; signs of
hypovolemia
Positive Murphy sign; palpable
gallbladder
4
ECG during episode of chest
pain, treadmill stress
testing, myocardial perfusion imaging
echocardiogram
WBC, ESR, ECG, chest
radiograph, echocardiogram
Echocardiogram, ECG,
chest radiograph
Chest radiograph, ECG,
echocardiogram
Chest radiograph,
sputum cultures, ABGs
ECG, echocardiogram
Chest radiography
Chest radiograph
None
None
Upper GI radiograph,
upper endoscopy, CBC
Gallbladder ultrasound
Continued
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Chapter 8 • Chest Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Nonemergent Chest Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute
pancreatitis
Lung tumors Chest pain, SOB, cough, hemopty-
Cocaine
and amphetamine use
Psychogenic
origin
Pleurodynia Severe, acute onset, stabbing,
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.
References and Readings
Bettmann MA, Lyders EM, Yucel EK, et al, Expert Panel on Cardiac
Imaging: Acute chest pain—suspected pulmonary embolism [online
publication]. Reston, Va., 2006, American College of Radiology.
Biondi E: Cardiac arrhythmias in children, Peds Rev 31:9, 2010.
Bonow RO, Mann DL, Zipes DP, Libby P: Braunwald’s heart disease: A
textbook of cardiovascular medicine, ed. 9, St. Louis, 2011, Elsevier.
Canadian Cardiovascular Society, American Academy of Family Phy-
sicians, American College of Cardiology, American Heart Associa-
tion, Antman EM, Hand M, Armstrong PW, 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.
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 noncar-
diac chest pain, Natl Clin Pract Gastroenterol Hepatol 2:10, 2005.
Etoom Y, Ratnapalan S: Evaluation of children with heart murmurs,
Clin Pediatr 20:5, 2013.
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, et al: Implications of recent
clinical trials for the National Cholesterol Education Program
Adult Treatment Panel III Guidelines, Circulation 110:227,
2004.
Severe epigastric or left upper quad-
rant abdominal pain radiating into
left chest; pain worse in supine
position; nausea, vomiting, fever
sis, history of cigarette smoking;
history of pneumonia
Chest pain, SOB, diaphoresis,
nausea; can relate to substance
use
Precordial chest pain, history of
stressful situations
paroxysmal, pleuritic pain over
lower rib cage and substernal
edge; headache, malaise,
nonproductive cough
Sudden, sharp, nondistressing
pain near apex of heart; seen in
adolescents
Left upper abdominal pain with
palpation; hypotension
Normal examination or diminished
breath sounds over tumor and
dull percussion sound over tumor
Tachycardia, hypertension ECG, serial cardiac
Normal examination ECG, chest radiograph,
Pleural friction rub 25% of time;
chest examination normal; fever
usually present
Normal examination Chest radiography, ECG
Hess EP, Thiruganasambandamoorthy V, Wells GA, et al: Diagnostic
accuracy of clinical prediction rules to exclude acute coronary
syndrome in the emergency department setting: A systematic review, Canadian J Emerg Med 10:373–382, 2008.
Imazio M, Cecchi E, Demichelis B, et al: Myopericarditis versus
viral or idiopathic acute pericarditis, Heart 94:498, 2008.
Kruip MJ, Leclercq MG, van der Heul C, et al: 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.
National Institute for Health and Care Excellence (NICE) Clinical
Guideline: Chest pain of recent onset, 2010. Retrieved from
http://guidance.nice.org.uk/CG95.
Reddy S, Singh H: Chest pain in children and adolescents, Pediatr
Review 31:929, 2010.
Selbst S: Approach to the child with chest pain, Pediatr Clin North
Am 57:6, 2010.
Swap CJ, Nagurney JT: Value and limitations of chest pain history in
the evaluation of patients with suspected acute coronary syn-
dromes, JAMA 294:20, 2005.
Wilbur J, Shian B: Diagnosis of deep venous thrombosis and pulmo-
nary embolism, Am Fam Physician 15:86, 913, 2012.
Wolff T, Guirguis-Blake J, Miller T, et al: Screening for asymptom-
atic carotid artery stenosis, Evidence Synthesis Number 50.
AHRQ Publication No. 08-05102-EF-1. Rockville, Md., Decem-
ber 2007, Agency for Healthcare Research and Quality.
Amylase, lipase,
pancreas ultrasound or
CT scan
Chest radiograph,
spiral CT of chest,
bronchoscopy
enzymes, drug screen
treadmill stress test if cardiac risk factors present.
Chest radiograph
CHAPTER
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9
onfusion is a symptom rather than a disease state.
C
It is the inability to think quickly or coherently. A
confused patient is disoriented to time, person, or place
and may 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.
Delirium, caused by alterations in brain metabolism,
is characterized by an abrupt onset, reduced level of
acute consciousness, and sleep/wake cycle disturbance.
Delirium is a medical emergency and can occur as a
result of medications, alcohol use or alcohol withdrawal,
narcotic reaction or narcotic withdrawal, WernickeKorsakoff syndrome (vitamin B
encephalopathy, acute illness, chronic illness, interacting diseases, or trauma (e.g., head injury).
Dementia, a chronic generalized impairment of brain
function, affects thinking but not the 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 9-1).
Depression as a cause of confusion, especially in
the elderly, is considered a reversible cause of dementia. When anxiety symptoms are also present, depression can manifest as mild delirium (see Chapter 4).
Confusion in Older Adults
deciency), hepatic
12
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
usual behavioral patterns and the conditions involved
with this episode.
Is this a condition that requires immediate intervention?
Key Questions
l
How suddenly did the confusion start?
l
Is the patient alert and aware of time, person, and
place?
l
Has the patient expressed thoughts of suicide (in
words or actions)?
l
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 along with the
current confusion indicates a 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 misusing alcohol or other chemical
substances, acute withdrawal can require immediate
medical intervention.
If the onset is gradual and the patient is not seriously
ill, consider depression and/or dementia. 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?
Key Questions
l
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)?
l
Does the confusion change within a 24-hour period
(stable or uctuating)?
l
Is there a change in the sleep pattern?
l
Is the patient alert and aware?
l
Has the patient experienced seeing, hearing, or feeling
things that are not there?
l
Is there any history of head trauma?
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Chapter 9 • Confusion in Older Adults
Box 9-1
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
Causes of Dementia
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 confusion episode, the symptoms are less
severe than with delirium and have a less sudden
onset. The onset of confusion 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.
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 24hour period.
Disturbance in Sleep/Wake Cycle
The sleep/wake cycle in delirium is impaired. Either
the patient gets little or no sleep or has night insomnia
and is drowsy and tired during the day. Thus the sleep/
wake cycle is usually fragmented, and the patient tends
to be restless, agitated, and hallucinates 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. In 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
l
Has the patient shown any tremor, especially at rest?
l
Has the patient had any trouble walking?
l
Has the patient reported severe headache and/or nausea?
l
Has the patient had a fever?
l
Has the patient gained or lost weight?
l
Does the patient engage in his/her usual activities?
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
associated infection, other systemic infections, or acute
alcohol withdrawal.
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.
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