3-11
the member to not want to move for fear of their life. Tamponade pain is sharp or discomfort associated with
fullness in the neck. Shingles pain is burning and localized to a dermatome, not crossing the midline and
confirmed by the development of blistering lesions.)
Duration: When did it start and how long did it last? Does it come and go? (Angina is usually relieved over 5
minutes while myocardial infarction pain may last for 30 minutes to an hour. Musculoskeletal pain may come
and go. Pneumothorax pain lasts until relieved by an intervention. Aortic dissection pain continues for hours.
Dyspepsia resolves in minutes with treatment.)
Alleviating or Aggravating Factors: What makes it better or worse? (Angina is brought on by exertion
and relieved by rest. Dyspepsia comes on after eating, is worsened by lying down and relieved by antacids.
Nothing relieves the pain of aortic dissection, perforated peptic ulcer or pneumothorax except narcotics.
Musculoskeletal pain is brought on by movement of the arms or chest and alleviated by not moving or
aspirin/NSAIDs. Gallstone pain is brought on by fatty foods. Movement of neck aggravates cervical disk pain.
Shingles pain is burning and worsened by clothing touching the area. Esophageal rupture is worsened by
eating or drinking and relieved only by narcotics. Eating or antacids relieve peptic ulcer disease pain. Drinking
cold liquids can bring on esophageal spasm. Pulmonary embolism pain is worsened by deep breaths and
partially relieved by oxygen.)
Associated Symptoms: Does the pain move anywhere? (Pain moving to the jaw or left arm suggests
a cardiac cause. Pain boring through to the back may be a peptic ulcer or aortic dissection. Pain moving
to the right shoulder blade is likely gall bladder. Pain moving to the top of the shoulder is likely to be a
pneumothorax or subacromial bursitis. Splenic pain may be referred to the left shoulder.) Are there other
symptoms? (Sweating, nausea, vomiting, shortness of breath are non-specific. Palpitations may accompany
heart disease but are also present whenever fear is present. An acid taste in the mouth [water brash]
suggests esophageal reflux. Pneumonia is associated with fever and a productive cough.)
Coronary Risk Factors: The presence of 3 or more coronary risk factors increases the likelihood of the
disease presence: smoking, hypertension, family history of heart attack before age 55, diabetes, high total
cholesterol, low HDL (good cholesterol), obesity, peripheral vascular disease.
Pearls:
- Pain that lasts seconds is not serious.
- Pain that moves from the chest into the arms and then the legs is not coronary disease.
- Pain relieved by nitroglycerin sublingual is smooth muscle: coronary or lower esophageal sphincter or
gall bladder or intestinal angina. - Chest pain resulting in collapse and shock is due to one of the life threatening causes.
- Anxiety and psychogenic chest pain can be sharp and last for seconds or be dull and last for days.
While it may be unresponsive to all empiric therapy, psychogenic chest pain remains a diagnosis of
exclusion.
Objective: Signs
Using Basic Tools: General: Pale, sweaty, cool clammy skin suggests decreased cardiac output; cyanosis
suggests PE. Vital Signs: Fever suggests infectious cause such as pneumonia or bronchitis. Irregular
pulse suggests cardiac cause. Absent pulses in the left arm or a blood pressure >10 mm lower than the
right suggest an aortic dissection. BP <100 systolic with heart rate >120 suggests decreased cardiac output
(e.g., tamponade, myocardial infarction and others). Respirations >30 suggest decreased cardiac output or
hypoxemia. Oxygen saturation <85 suggests pulmonary embolism but may be present with pneumothorax
or MI with pulmonary edema.
Neck Veins: Elevated suggests tamponade.
Chest Wall: Point tenderness over the costochondral junction or the intercostal muscles suggests chest wall
pain (inflammation of the costochondral junction, muscle strain). Numbness in a subcostal nerve distribution
suggests nerve injury from trauma. Lateral compression of the chest cage will accentuate pain from a rib
fracture. Tenderness and warmth of the breast suggests mastitis.
Lungs: Absence of breath sounds or increased resonance to percussion suggests pneumothorax. A shift in
the trachea supports a tension pneumothorax. Fine-crackling sounds of fluid (rales) in the alveoli suggests
cardiac cause. Coarse crackling sounds (rhonchi) suggest pneumonia or bronchitis. A finding of consolidation
(E->A change) suggests pneumonia.
Heart: Irregular beating suggests cardiac cause. Muffled sounds suggest tamponade or pneumothorax.