History in the patient with chest pain :
A careful history of the chest pain will generally be suggestive of the likely underlying problem. It is important duringthe history to take note of any procedures that have been done and what doctors the patient has seen over the pastfew years. In addition, social history (drug use and occupation) and psychiatric history can provide insight into thenature of chest pain (e.g., anxiety disorder, cocaine-induced MI). The focus should then turn to any associatedsymptoms and risk factors.
What type of chest pain does the patient have?Onset and progression of pain
Cardiac ischemic pain typically builds up over a few minutes and may be brought on by exercise, emotion, or coldweather. In angina the pain resolves on resting or with sublingual nitroglycerin (NTG). In unstable angina the pain maycome on at rest and commonly waxes and wanes, becoming severe at times. In MI the pain is severe, often associatedwith systemic symptoms such as nausea, vomiting, and sweating, and lasts for at least 30 minutes. Spontaneouspneumothorax and pulmonary embolism usually causes sudden onset of pleuritic pain (patients often remember exactlywhat they were doing at the time). Pain that follows an episode of vomiting, especially if hematemesis is present,suggests esophageal disease.
Site and radiation of pain
Cardiac ischemia and pericarditis cause retrosternal pain. In ischemia, the pain often radiates to the jaw, neck, orarms, while dissecting aortic aneurysm causes a tearing interscapular pain, and pulmonary disease causes unilateral painwhich the patient can often localize specifically. Esophageal disease can also cause retrosternal pain and may mimiccardiac pain. Referred pain from vertebral collapse or shingles will follow a dermatome pattern.A note about shingles: Lesions never cross the midline except in patients with immunocompromise, which may beiatrogenic (e.g., steroid use) or due to another cause. In addition, the pain of shingles can begin before the rashappears. Patients complain of "electrical" type pain. Treatment with acyclovir is effective only if given within 24 hoursof the initial rash.
Nature of pain
The precise nature of the pain gives important clues as to the underlying diagnosis-for instance, crushing, sharp,pleuritic, burning, or stabbing (see above).
Are there any associated symptoms?Important associated symptoms include:
Dyspnea: pulmonary embolism, pneumonia, pneumothorax, pulmonary edema in cardiac ischemia, hyperventilation inanxiety.
Cough: purulent sputum in pneumonia, hemoptysis in pulmonary embolism, frothy pink sputum in pulmonary edema.
Rigors: pneumonia (particularly lobar pneumonia).Calf swelling: has PE arisen from deep vein thrombosis? Bilateral swelling suggests heart failure.
Palpitations: arrhythmia can cause angina or result from cardiac ischemia, PE, or pneumonia.
Clamminess, nausea, vomiting, and sweating are features of myocardial infarction or massive pulmonary embolism.
Do not forget about anginal equivalents
, such as those listed above, or jaw pain/tightness or indigestion. Anginalequivalents may be the only presenting symptoms of an MI, especially in elderly and diabetic patients. When in doubt,get an ECG and cardiac enzymes.
Are risk factors present?
Important risk factors include:
Ischemic heart disease: smoking, family history, cholesterol, hypertension, diabetes, male sex, age over 50 years.
PE: recent travel, immobility, or surgery, family history, pregnancy, malignancy.
Pneumothorax: spontaneous (young, thin men), trauma, emphysema, asthma, malignancy, staphylococcalpneumonia, cystic fibrosis.