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CHEST PAIN
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141
Chest pain
Chest pain usually results from disorders that
affect thoracic or abdominal organs—the
heart, pleurae, lungs, esophagus, rib cage,
gallbladder, pancreas, or stomach. An important indicator of several acute and life-threatening cardiopulmonary and GI disorders, chest
pain can also result from a musculoskeletal or
hematologic disorder, anxiety, and drug
therapy.
Chest pain may arise suddenly or gradually,
and its cause may be difficult to ascertain initially. The pain may radiate to the arms, neck, jaw,
or back. It may be steady or intermittent and
mild or acute, and it may range in character
from a sharp shooting sensation to a feeling of
heaviness, fullness, or even indigestion. Chest
pain may be provoked or aggravated by stress,
anxiety, exertion, deep breathing, or eating certain foods.
EMERGENCY INTERVENTIONS Ask the
patient when his chest pain began. Did it develop suddenly or gradually? Is it more severe or
frequent now than when it first started? Does anything relieve the pain? Does anything aggravate it?
Ask the patient about associated symptoms. Sudden, severe chest pain requires prompt evaluation
and treatment because it may herald a life-threatening disorder. (See Managing severe chest pain,
pages 142 and 143.)
H
ISTORY AND PHYSICAL
EXAMINATION
If the chest pain isn’t severe, proceed with the
history. Ask if the patient feels diffuse pain or
can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling
as pain, so ask whether he has any discomfort
radiating to his neck, jaw, arms, or back. If he
does, ask him to describe it. Is it a dull, aching,
pressurelike sensation? A sharp, stabbing,
knifelike pain? Does he feel it on the surface or
deep inside? Find out whether it’s constant or
intermittent. If it’s intermittent, how long does it
last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens
or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or
pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent
dosage or schedule changes.
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension.
Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction
rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate
for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops,
tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated
findings, pages 144 to 147.)
M
EDICAL CAUSES
◆ Angina pectoris. A patient with angina pec-
toris may experience a feeling of tightness or
pressure in the chest that he describes as pain
or a sensation of indigestion or expansion. The
pain usually occurs in the retrosternal region
over a palm-sized or larger area. It may radiate
to the neck, jaw, and arms—classically, to the
inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly
subside. Provoked by exertion, emotional stress,
or a heavy meal, the pain typically lasts 2 to
10 minutes (usually no longer than 20 minutes).
Associated findings include dyspnea, nausea,
vomiting, tachycardia, dizziness, diaphoresis,
belching, and palpitations. You may hear an
atrial gallop (a fourth heart sound [S
murmur during an anginal episode.
In Prinzmetal’s angina, caused by vasospasm
of coronary vessels, chest pain typically occurs
when the patient is at rest—or it may awaken
him. It may be accompanied by dyspnea, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.
]) or a
4
◆ Anthrax (inhalation). This acute infectious
disease is caused by the gram-positive, sporeforming bacterium Bacillus anthracis. Although
the disease most commonly occurs in wild and
domestic grazing animals, such as cattle, sheep,
and goats, the spores can live in the soil for
many years. The disease can occur in humans
exposed to infected animals, tissue from infected animals, or biological agents. Most natural
cases occur in agricultural regions worldwide.
Anthrax may occur in cutaneous, inhalation, or
GI forms.
Inhalation anthrax is caused by inhalation of
aerosolized spores. Initial flulike signs and
symptoms include fever, chills, weakness,
(Text continues on page 145.)
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EMERGENCY INTERVENTION
Managing severe chest pain
Sudden, severe chest pain may result from any one of several life-threatening disorders.
Your evaluation and interventions will vary, depending on the pain’s location and character. The flowchart below will help you establish priorities for managing this emergency
successfully.
Ask the patient to characterize his chest pain.
Patient reports sudden onset of pleuritic
chest pain, which he characterizes as
crushing, shooting, and deep.
Assess him for diaphoresis, dyspnea,
tachypnea, hemoptysis, and tachycardia.
If you detect these signs and symptoms,
suspect pulmonary embolism.
What to do: Quickly take the patient’s vital signs. Obtain a 12-lead electrocardiogram.
Insert an I.V. catheter to administer fluids and drugs, and give oxygen. Check the patient’s vital signs
frequently to detect changes from baseline. Begin cardiac monitoring to detect arrhythmias.
As appropriate, prepare the patient for emergency surgery. Prepare patients with pulmonary
embolism or myocardial infarction for possible thrombolytic therapy.
Patient reports sudden onset of tearing,
ripping, stabbing chest pain, with
syncope and hemiplegia.
Assess him for differences in blood
pressure between legs and arms as well
as weak or absent femoral or
pedal pulses.
If you detect these signs, suspect
dissecting aortic aneurysm.
Patient reports sudden onset of severe
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substernal pain that radiates to his left
arm, jaw, neck, or shoulder blades; he
describes the pain as a squeezing,
viselike, burning sensation.
CHEST PAIN 143
Patient reports sudden onset of
diffuse chest tightness.
Assess him for pallor, diaphoresis,
nausea, vomiting, apprehension, anxiety,
weakness, fatigue, and dyspnea.
If you detect these signs and symptoms,
suspect myocardial infarction.
Assess him for wheezing, dry cough,
chest tightness, dyspnea, tachycardia,
and hyperventilation.
If you detect these signs and symptoms,
suspect an acute asthma attack.
What to do: Try to calm the patient to
slow his respiratory rate. Ask the patient
if he’s ever had this pain before and, if so,
what (if anything) eased it. Give oxygen
and insert an I.V. catheter to administer
fluids and drugs. Expect to give
epinephrine and a bronchodilator and to
begin respiratory therapy.
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SIGNS & SYMPTOMS
Chest pain: Causes and associated findings
Major associated signs and symptoms
Common
causes
Angina pectoris
Anthrax (inhalation)
Anxiety
Aortic aneurysm
(dissecting)
Asthma
Blast lung injury
Blastomycosis
Bronchitis
Cardiomyopathy
Cholecystitis
Coccidioidomycosis
Costochondritis
Distention of
colon’s splenic
flexure
Esophageal spasm
Herpes zoster
(shingles)
Hiatal hernia
Interstitial lung
disease
Legionnaires’
disease
Lung abscess
Lung cancer
Mediastinitis
Mitral valve
prolapse
Abdominal mass
Abdominal
tenderness
Atrial gallop
Breath sounds,
decreased
Cough
Crackles
Cyanosis
Diaphoresis
Dizziness
Dyspnea
Fever
Hemoptysis
Murmur
•
••••
•
••
••
•• • •
•••
•
•
•••
••
•
•
•
•
•• •
•
•
•
•
•
•
••
•
••
•
•
••• •
••
•••
••• • •••
•••
•
•
•
••
cough, and chest pain. The disease generally
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occurs in two stages with a period of recovery
after the initial signs and symptoms. The second
stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and
hypotension; death generally results within
24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.
◆ Anxiety. Acute anxiety—commonly known
as panic attacks—can produce intermittent,
sharp, stabbing pain, typically behind the left
Nausea and
vomiting
Pericardial friction
rub
Pleural friction rub
Skin mottling
Syncope
Tachycardia
Tachypnea
••
•••
•••
••
•
•
•
•
•
•
•
•
•
•
••
•
•
•
(continued)
breast. This pain isn’t related to exertion and
Wheezing
lasts only a few seconds, but the patient may
experience a precordial ache or a sensation of
heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea,
and tremors. Panic attacks may be associated
with agoraphobia—fear of leaving home or being in open places with other people.
◆ Aortic aneurysm (dissecting). The chest
pain associated with this life-threatening disorder usually begins suddenly and is most severe
at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest
and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal
mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic
bruit, systemic hypotension, asymmetrical
brachial pulses, lower blood pressure in the legs
than in the arms, and weak or absent femoral
or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill
time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid
arteries.
◆ Asthma. In a life-threatening asthma attack,
diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related
respiratory findings include rhonchi, crackles,
prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory
muscle use, flaring nostrils, and tachypnea. The
patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.
◆ Blast lung injury. Caused by a percussive
shock wave after an explosion, blast lung injury
can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the
CHEST PAIN 145
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Chest pain: Causes and associated findings (continued)
Major associated signs and symptoms
Common
causes
Muscle strain
Myocardial
infarction
Nocardiosis
Pancreatitis
Peptic ulcer
Pericarditis
Plague
Pleurisy
Pneumonia
Pneumothorax
Psittacosis
Pulmonary
actinomycosis
Pulmonary
embolism
Abdominal mass
Abdominal
tenderness
Atrial gallop
•
•
Breath sounds,
decreased
Cough
Crackles
Cyanosis
Diaphoresis
•
•
•••
••••
••
•
•••
•
•
••
•• •
•
•
•
•
••• ••
Dizziness
Dyspnea
••
•
Fever
Hemoptysis
Murmur
•
•
••
•••
•
•
••
•
Pulmonary
hypertension
(primary)
Q fever
Rib fracture
Sickle cell crisis
Thoracic outlet
syndrome
Tuberculosis
Tularemia
•
•
•
•
•
•
•
••
•
•
•
•
••
••
Nausea and
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vomiting
Pericardial friction
•
•
•
•
rub
Pleural friction rub
Skin mottling
••
•
Syncope
•
Tachycardia
Tachypnea
•
•
•
•
•
•
•••
Wheezing
•
CHEST PAIN 147
lungs of affected people. Worldwide terrorist activity has recently increased the incidence of
this condition, which may also cause dyspnea,
hemoptysis, wheezing, and cyanosis. Chest Xrays, arterial blood gas measurements, and
computed tomography scans are common diagnostic tools. Although no definitive guidelines
exist for caring for those with blast lung injury,
treatment is based on the nature of the explosion, the environment in which it occurred, and
any chemical or biological agents involved.
◆ Blastomycosis. Besides pleuritic chest pain,
this disorder initially produces signs and symptoms that mimic those of a viral upper respiratory tract infection: a dry, hacking, or productive
cough (and sometimes hemoptysis), fever,
chills, anorexia, weight loss, fatigue, night
sweats, and malaise.
◆ Bronchitis. In its acute form, this disorder
produces burning chest pain or a sensation of
substernal tightness. It also produces a cough,
initially dry but later productive, that worsens
the chest pain. Other findings include a lowgrade fever, chills, sore throat, tachycardia,
muscle and back pain, rhonchi, crackles, and
wheezing. Severe bronchitis causes a fever of
101° to 102° F (38.3° to 38.9° C) and possibly
bronchospasm with increased coughing and
wheezing.
◆ Cardiomyopathy. In hypertrophic cardiomy-
opathy, angina-like chest pain may occur with
dyspnea, a cough, dizziness, syncope, gallops,
murmurs, and palpitations.
◆ Cholecystitis. This disorder typically pro-
duces abrupt epigastric or right-upperquadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may
radiate to the back or the right shoulder. Associated findings commonly include nausea,
vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an
abdominal mass, rigidity, distention, or tenderness. Murphy’s sign—inspiratory arrest elicited
when the examiner palpates the right upper
quadrant as the patient takes a deep breath—
may also occur.
◆ Coccidioidomycosis. In this disorder,
pleuritic chest pain occurs with a dry or
slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional
chills, sore throat, backache, headache,
malaise, marked weakness, anorexia, and a
macular rash.
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◆ Costochondritis. Pain and tenderness occur
at the costochondral junctions, especially at the
second costicartilage. The pain usually can be
elicited by palpating the inflamed joint.
◆ Distention of colon’s splenic flexure. Cen-
tral chest pain may radiate to the left arm in patients with this disorder. The pain may be relieved by defecation or the passage of flatus.
◆ Esophageal spasm. In this disorder, subster-
nal chest pain may last up to an hour and may
radiate to the neck, jaw, arms, or back. It commonly mimics the squeezing or dull sensation
associated with angina. Other signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.
◆ Herpes zoster (shingles). The pain of pre-
eruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is
characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red,
nodular lesions erupt on the painful areas—
usually the thorax, arms, and legs—and the
chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.
◆ Hiatal hernia. Typically, this disorder pro-
duces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the
left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends
over or lies down. Other findings include a bitter
taste and pain while eating or drinking, especially spicy foods and hot drinks.
◆ Interstitial lung disease. As this disease ad-
vances, the patient may experience pleuritic
chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough,
fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.
◆ Legionnaires’ disease. This disorder pro-
duces pleuritic chest pain in addition to malaise,
headache, and possibly diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12
to 24 hours, the patient suddenly develops a
high fever and chills, and an initially nonproductive cough progresses to a productive cough
with mucoid and then mucopurulent sputum
and possibly hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea,
and tachycardia.
◆ Lung abscess. Pleuritic chest pain develops
insidiously in a lung abscess along with a
pleural friction rub and a cough that produces
copious amounts of purulent, foul-smelling,
blood-tinged sputum. The affected side is dull
on percussion, and decreased breath sounds
and crackles may be heard. The patient also
displays diaphoresis, anorexia, weight loss,
fever, chills, fatigue, weakness, dyspnea, and
clubbing.
◆ Lung cancer. The chest pain associated
with lung cancer is commonly described as an
intermittent aching felt deep within the chest.
If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous,
and gnawing. Associated findings include a
cough (sometimes blood-tinged), wheezing,
dyspnea, fatigue, anorexia, weight loss, and
fever.
◆ Mediastinitis. This disorder produces severe
retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen
with breathing, coughing, or sneezing. Accompanying signs and symptoms include chills,
fever, and dysphagia.
◆ Mitral valve prolapse. Most patients with
mitral valve prolapse are asymptomatic, but
some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can
last for seconds or hours and may mimic the
pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click
followed by a systolic murmur at the apex. The
patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic
severe fatigue, dyspnea, tachycardia, mood
swings, and palpitations.
◆ Muscle strain. Strained chest, arm, or shoul-
der muscles may cause a superficial and continuous ache or “pulling” sensation in the chest.
Lifting, pulling, or pushing heavy objects may
aggravate this discomfort. With acute muscle
strain, the patient may experience fatigue,
weakness, and rapid swelling of the affected
area.
◆ Myocardial infarction. The crushing sub-
sternal chest pain typically associated with an
MI lasts from 15 minutes to hours. Typically unrelieved by rest or nitroglycerin, the pain may
radiate to the patient’s left arm, jaw, neck, or
shoulder blades. Other findings include pallor,
clammy skin, dyspnea, diaphoresis, nausea,
vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an
atrial gallop, murmurs, and crackles.
GENDER CUE An MI may be difficult to di-
agnose in perimenopausal women because
it may produce atypical symptoms, such as
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149
fatigue, nausea, dyspnea, and shoulder or neck
pain, rather than chest pain.
◆ Nocardiosis. This disorder causes pleuritic
chest pain with a cough that produces thick,
tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also
cause fever, night sweats, anorexia, malaise,
weight loss, and diminished or absent breath
sounds.
◆ Pancreatitis. Acute pancreatitis usually
causes intense epigastric pain that radiates to
the back and worsens when the patient is in a
supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished
bowel sounds, and crackles at the lung bases
may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes
massive hemorrhage, resulting in shock and
coma.
◆ Peptic ulcer. In this disorder, sharp and
burning pain usually arises in the epigastric region. This pain characteristically occurs hours
after food intake, commonly during the night. It
lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood),
melena, and epigastric tenderness.
◆ Pericarditis. This disorder produces precor-
dial or retrosternal pain that’s aggravated by
deep breathing, coughing, position changes,
and occasionally by swallowing. The pain is
commonly sharp or cutting and radiates to the
shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever,
tachycardia, and dyspnea. Pericarditis usually
follows a viral illness, but several other causes
should be considered.
◆ Plague. Caused by Yersinia pestis, plague is
one of the most virulent and, if untreated, most
lethal bacterial infections known. Most cases
are sporadic, but the potential for epidemic
spread still exists. Clinical forms include
bubonic (the most common), septicemic, and
pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas.
Signs and symptoms include fever, chills, and
swollen, inflamed, and tender lymph nodes
near the site of the fleabite. Septicemic plague
may develop as a complication of untreated
bubonic or pneumonic plague and occurs when
the plague bacteria enter the bloodstream and
multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an in-
fected person or inhaling the organism that has
been dispersed in the air through biological
warfare. The onset is usually sudden with
chills, fever, headache, and myalgia. Pulmonary
signs and symptoms include a productive
cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
◆ Pleurisy. The sharp, even knifelike chest
pain of pleurisy arises abruptly and reaches
maximum intensity within a few hours. The
pain is usually unilateral and located in the
lower and lateral aspects of the chest. Deep
breathing, coughing, or thoracic movement
characteristically aggravates it. Auscultation
over the painful area may reveal decreased
breath sounds, inspiratory crackles, and a
pleural friction rub. Dyspnea, rapid and shallow
breathing, cyanosis, fever, and fatigue may also
occur.
◆ Pneumonia. This disorder produces pleuritic
chest pain that increases with deep inspiration
and is accompanied by shaking chills and fever.
The patient has a dry cough that later becomes
productive. Other signs and symptoms include
crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal
pain, anorexia, cyanosis, decreased breath
sounds, and diaphoresis.
◆ Pneumothorax. Spontaneous pneumotho-
rax, a life-threatening disorder, causes sudden
severe, sharp chest pain that increases with
chest movement; it’s typically unilateral and
rarely localized. When the pain is centrally located and radiates to the neck, it may mimic
that of an MI. After the pain’s onset, dyspnea
and cyanosis progressively worsen. Breath
sounds are decreased or absent on the affected
side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory
muscle use, a nonproductive cough, tachypnea,
tachycardia, anxiety, and restlessness also
occur.
◆ Psittacosis. This disorder may produce pleu-
ritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration.
◆ Pulmonary actinomycosis. This disorder
causes pleuritic chest pain with a cough that’s
initially dry but later produces purulent sputum.
The patient may also display hemoptysis, fever,
weight loss, fatigue, weakness, dyspnea, and
night sweats. Multiple sinuses may extend
through the chest wall and drain externally.
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◆ Pulmonary embolism. This disorder pro-
duces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain
aggravated by deep breathing and thoracic
movement. Other findings include tachycardia,
tachypnea, cough (nonproductive or producing
blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction
rub, diffuse wheezing, dullness on percussion,
signs of circulatory collapse (weak, rapid pulse;
hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness,
coma, seizures), signs of hypoxia (restlessness)
and, particularly in the elderly, hemiplegia and
other focal neurologic deficits. Less-common
signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck
veins.
◆ Pulmonary hypertension (primary). Angina-
like pain develops late in patients with this disorder, usually on exertion. The precordial pain
may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and
hemoptysis.
◆ Q fever. Q fever is a rickettsial disease
caused by Coxiella burnetii, an organism found
in cattle, sheep, and goats. Human infection
usually results from exposure to contaminated
milk, urine, feces, or other fluids from infected
animals, but it may also result from inhalation
of contaminated barnyard dust. C. burnetii is
highly infectious and is considered a possible
airborne agent for biological warfare. Signs and
symptoms include fever, chills, severe
headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to
2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
◆ Rib fracture. The chest pain due to frac-
tured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on
the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the
fracture site.
◆ Sickle cell crisis. Chest pain associated with
sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain
worsens, it becomes generalized or localized to
the abdomen or chest, causing severe pleuritic
pain. The presence of chest pain and difficulty
breathing requires prompt intervention. The patient may also have abdominal distention and
rigidity, dyspnea, fever, and jaundice.
◆ Thoracic outlet syndrome. Often causing
paresthesia along the ulnar distribution of the
arm, this syndrome can be confused with angina, especially when it affects the left arm. The
patient usually experiences angina-like pain after lifting his arms above his head, working with
his hands above his shoulders, or lifting a
weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include
pale skin and a difference in blood pressure between both arms.
◆ Tuberculosis. Pleuritic chest pain and fine
crackles occur after coughing in a patient
with tuberculosis. Associated signs and symptoms include night sweats, anorexia, weight
loss, fever, malaise, dyspnea, easy fatigability,
mild to severe productive cough, occasional
hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath
sounds.
◆ Tularemia. Also known as “rabbit fever,”
this infectious disease is caused by the gramnegative, non–spore-forming bacterium Fran-
cisella tularensis. This organism is found in wild
animals, water, and moist soil, typically in rural
areas. It’s transmitted to humans through the
bite of an infected insect or tick, the handling of
infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for
biological warfare. Signs and symptoms following inhalation of the organism include the
abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea,
pleuritic chest pain, and empyema.
O
THER CAUSES
◆ Chinese restaurant syndrome. This benign
condition—a reaction to excessive ingestion of
monosodium glutamate, an additive in Chinese
foods—mimics the signs of an acute MI. The patient may complain of retrosternal burning,
ache, or pressure; a burning sensation over his
arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.
◆ Drugs. Abrupt withdrawal of a beta-adrener-
gic blocker can cause rebound angina if the patient has coronary artery disease, especially if
he has received high doses for a prolonged
period.
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