DIAGNOSIS OF CHEST PAIN

Dr Umair Ahmed
  Unstable Angina/Acute Coronary
Insufficiency
 Pain and pressure in the chest and intrascapular region
with possible radiation to the arms, neck, torso, or jaw
with symptoms lasting 20 to 30 minutes or occurring at
rest
 Variant Angina
 pain and pressure in the chest or between shoulder blades
that may or may not radiate to arms, neck, torso, or jaw that
occurs spontaneously, often in the morning hours, causing the
patient to be awakened with pain.2,5
 Symptoms are variable and do not always occur at the same
activity level.
 Symptoms may not be resolved with nitroglycerin.
 Diagnosis is made by echocardiography, echocardiographic
changes or symptom provocation during a cardiac stress test,
angiogram,2,4,5 serial blood tests (cardiac troponin T or I or
CK-MB),2–4 or symptom provocation with use of medication
that produces artery spasm.
 Aortic Dissection (Ascending Aorta or Thoracic
Descending Aorta)
 Sudden “tearing” or “ripping” pain in the anterior chest with radiation to the
intrascapular region, accompanied by diaphoresis, syncope, or weakness.
 Pain may migrate into abdomen and lower back as dissection progresses.
 Symptoms peak immediately and are not affected by change in position
 Other findings include hypertension or hypotension, loss of pulses, and pulmonary
edema.
 Individuals most at risk for this diagnosis are those with Marfan’s syndrome, Ehlers-
Danlos syndrome, systemic hypertension, congenital aortic anomalies, and women in
their third trimester of pregnancy.
 This condition most commonly occurs in people between 60 and 70 years of age.
Men are twice more likely to be affected than women.
 Compression of surrounding structures and/or ischemia may cause neurological
findings (compression of nerves or cord ischemia) or other complications
Bronchitis
 Chest tightness and burning anterior chest pain that is
worsened by a dry cough that later becomes productive.
 Patient may also develop a fever or bronchospasm as the
disease progresses.
 These symptoms may be associated with muscular and
joint dysfunctions related to increased coughing and
pressure on the chest.
 Individuals with this condition may also have exertional
dyspnea and difficulty sleeping.
 Chest Pain With Panic Attack
 Left anterior chest of a sharp, stabbing nature.
 In addition, patient may have palpitations, sweating, light-
headedness, gastrointestinal distress, nausea, chills or hot
flushes, vomiting, shortness of breath, and restlessness or a
feeling of nervousness.
 Tachycardia, elevated blood pressure, and moist palms may
be present.
 Diagnosis is confirmed by negative tests for cardiac disease
such as echocardiography and blood tests, although some
patients may present with echocardiographic changes
 Chest Pain Without Panic Attack
 Pain in the left anterior chest of a sharp, stabbing nature. Pain
maybe sporadic, lasting only for a few seconds, but recurring
several times per minute for extended periods of time.
 Often pain is a constant ache lasting for hours or days.
 Another presentation is a subjective description of pressure in
throat and chest.
 Pain and Paresthesias may radiate to arm.
 Diagnosis is confirmed by negative tests for cardiac disease
such as echocardiography and blood tests, although some
patients may present with echocardiographic changes.
 Esophageal Rupture
 Anterior chest pain in the retrosternal region.
 Depending on the location of rupture, the pain may be severe or mild.
 Often pain will worsen with swallowing or breathing.
 Patients with this condition may present with dyspnea and cyanosis.
 Air entering the mediastinum may cause crackling sounds on auscultation
and pneumothorax.
 A mediastinal shift may also occur.
 The rupture may be caused by an instrument during endoscopy, external
trauma, increased pressure during forceful vomiting or weight lifting, or
by diseases of the esophagus (ulcer, esophagitis, and neoplasm).
 Gastroesophageal Reflux Disease
 A dull anterior chest pain usually in the region of the lower
sternum.
 The pain may radiate and is often associated with food
intake, especially large meals.
 Symptoms may be worsened by bending forward or lying
down.
 Some patients may report flatulence, hoarseness, sleep
apnea, dyspnea, halitosis, difficulty swallowing, and (rarely)
hematemesis.
 This may be related to acid hypersecretion, hiatal hernia,
obesity, decreased lower esophageal tone, and/or presence
of Helicobacter pylori bacteria in the stomach.
 Hyperventilation
 chest pain, abdominal pain, rapid or deep breathing,
lightheadedness, and arm/face tingling.
 Echocardiography may be altered, resulting in ST-T wave
abnormalities.
 Clinical tests include deep breathing (as deep and fast as
possible) for 2 minutes.
 Hypochondriasis
 A variety of chest pain complaints and the belief that
these symptoms are related to a very severe medical
illness despite medical evaluation and reassurance.
 The patient reports somatic symptoms that cannot be
explained by a known medical condition
 Infectious Esophagitis
 anterior chest pain with possible dysphasia, painful
swallowing, and weight loss.
 Individuals with carcinoma related to acquired
immunodeficiency syndrome, diabetes mellitus, acid
suppression, gastric surgery, or steroid use (oral or
inhaled) are at increased risk.
 The diagnosis is confirmed with a barium swallowing
examination, endoscopy with brush specimens of tissue, or
biopsy.
 INFECTIOUS ESOPHAGITIS (SECONDARY)
Candida Species Infection
 Anterior chest pain and may include dysphagia, painful
swallowing, oral thrush, or bleeding.
 Cytomegalovirus
 Anterior chest pain, painful swallowing, hematemesis,
nausea, and vomiting.
 Most individuals suspected of this condition will have some
degree of immunodeficiency, such as with human
immunodeficiency virus or patients who received
transplants.
 Transmission occurs by way of multiple routes, such as
droplets, sexual contact, and blood transfusions.
 Sites of infection may include the eye, brain, and
gastrointestinal tract.
 Herpes Simplex Virus
 Anterior chest pain, painful swallowing, dysphasia,
vomiting, fever, and chills
 Malingering
 consciously and intentionally produced physical
symptoms in order to obtain some external reward.
MEDICATION OR STIMULANT USE/ABUSE
 Nonspecific chest pain after prescriptive or recreational
use of stimulant medication.
 The patient may be of any age group, ethnicity, or sex.
Illicit Substances Amphetamine, Cocaine, or
“Crack” Use/Abuse
 Chest pain, palpitations, hypertension, faintness, panic
attacks, loss of consciousness, seizures, and heart failure.
 Up to 25% of acute myocardial infarction cases in 18- to
45-year-old patients are related to cocaine use
 Ecstasy/3,4-Methylenedioxymethamphetamine
(MDMA) Use/Abuse
 Chest pain in adolescents and young adults in a broad
range of ethnic groups.
 Caffeine Use/Abuse
 This presentation has been inconsistently correlated to an
increase in angina pectoris and acute coronary syndromes.
 Monosodium Glutamate
 Intake acute chest pain, burning, pressure, and shortness
of breath.
 Pseudoephedrine (Allergy/Cold Medicine)
Use/Abuse
 sufficient chest pain in adults and adolescents to cause
the patient to seek emergency care.
 Beta-Agonist Use
 Chest pain in pregnant women.
 This substance is sometimes used during pregnancy to
prevent preterm labor
 Bronchodilators/Nonspecific Beta-Agonist
 Use This presentation typically involves an increase in
heart rate and palpitations that may be associated with
chest pain in an individual with asthma who recently used
an inhaler or handheld nebulizer
 One substance, Proventil (albuterol), also may cause
paradoxical bronchospasm
 Withdrawal From Beta Blockers
 The presentation of this condition typically involves a
rebound increase in angina in an individual who recently
ceased taking betablocker medication
 Myocardial Infarction
 pain and pressure in the chest or between shoulder
blades that may or may not radiate to arms, neck, torso,
or jaw.
 Pain may be slightly eased by flexing the shoulders and
worsened by deep breaths and/or activity.
 Pericarditis
 Anterior chest pain, which may radiate up toward the
neck, that is relieved with sitting up, standing, and leaning
forward; the pain is worsened with lying supine.
 Pain also may be worsened with deep breathing or
coughing.
 A friction rub is audible during cardiac auscultation.
 Pleurisy/Pleurodynia
 Sharp and stabbing pain in the anterior or lateral chest
(unilateral or bilateral) that is made worse by deep
inspiration, by movements, and in some cases by lying
down.
 Pain may be constant or intermittent, lasting 2 to 10 hours
at a time. Fever may or may not be present.
 Pleuritis Secondary to Rheumatic Disease
 Pain in the anterior or lateral chest (unilateral or
bilateral), typically in an individual with a history of
rheumatoid arthritis or systemic lupus erythematosus.
 Pain is sharp and stabbing in nature.
 It is made worse by deep inspiration, by movements, and
in some cases by lying down.
 Pain may be constant or intermittent, lasting 2 to 10 hours
at a time.
Pneumonia
 This presentation typically involves “stabbing” or “sharp”
unilateral or bilateral anterior chest pain that may radiate
to the shoulders;
 it is worsened with arm and neck movements or deep
inspiration.
 Onset may be gradual or sudden, beginning with a dry
cough and often other symptoms such as myalgias,
headache, or gastrointestinal distress
 Pneumothorax
 Sudden, sharp unilateral chest pain in the anterior or lateral
chest, worsened with deep inspiration and potentially
accompanied by shortness of breath or rapid breathing
 Tracheal deviation contralateral to the side of the
pneumothorax and jugular venous distension may be observed
(Fig. 14-1).
 Tachycardia, hypotension, and tachypnea may be present,
and breath sounds may be absent.
 Spontaneous pneumothorax occurs most commonly in people
20 to 40 years of age often preceded by strenuous activity,
coughing, or prolonged Valsalva maneuver (as is common
during cocaine use).
 Pulmonary Embolism/Infarction
 Chest and throat pain often accompanied by dyspnea
and worsened by thoracic spine movements and deep
breathing.
 Evaluation may reveal tachycardia, cough, fever,
diaphoresis, cyanosis, and clubbing of fingernails.
 Sickle Cell Pain Crisis
 Diffuse pain that progresses to pain in limbs and in the
chest and sometimes back.
 The pain is aggravated by movement and deep
breathing.
 The chest wall may be tender to palpation especially
along the ribs and intercostal region.
 Pain is often caused by rib infarctions.
 Dyspnea and fever also may be present.
 Subdiaphragmatic Abscess
 Chest and shoulder pain that is made worse by movement,
breathing, coughing, and sneezing.
 Upper abdomen may be tender and patient may have a
fever.
 This condition may occur secondary to abdominal surgery
or perforation of the bowel or gallbladder
 Tracheobronchitis
 anterior chest pain that may be increased by cough or
breathing, productive cough, fever, and sometimes
bronchospasm.
 This condition is often caused by viral or bacterial
infection.
 Crackles, rhonchi, and wheezes may be heard to
auscultation in midline position.
 Tuberculosis
 Chest pain, productive or nonproductive cough, malaise,
and dyspnea.
 Chest pain is caused by irritation of the pleura.
 A friction rub can often be heard during auscultation.
 This condition is most common in patients under 30 years
of age.
 Chest plain radiographs confirm the diagnosis. Fluid in the
lungs may be noted on radiographs and a tuberculin skin
test is positive.
 TUMORS
 Esophageal Tumor
 Anterior chest pain with possible dysphagia, painful swallowing, and
weight loss.
 Pain is caused by irritation of the esophagus similar to that of
esophagitis.
 Painful swallowing and dysphagia are caused by the tumor blocking
the path of swallowed food. Late symptoms include hoarseness,
hiccups, pneumonia, and high blood calcium levels.
 Risk factors include age greater than 70 years old, male sex, African
American race, history of Barrett’s esophagus or gastroesophageal
reflux disease, tobacco use, long-term heavy alcohol use, obesity,
drinking very hot liquids, a diet lacking fruits and vegetables,
occupational exposure to chemicals used in dry cleaning, and history
of lye ingestion.
 Lung Tumor
 chest pain, arm pain, dyspnea, hoarseness, and cough, sometimes
with blood-tinged sputum.
 Pain may be caused by pleural irritation or may be caused my
pressure of the tumor on local structures such as a nerve root.
 Pleuritic pain includes sharp and stabbing pain in the anterior or
lateral chest (unilateral or bilateral) that is made worse by deep
inspiration, by movements, and in some cases by lying down.
 Pain may be constant or intermittent, lasting 2 to 10 hours at a
time. Some individuals with this condition may also describe
weight loss, shortness of breath, or loss of appetite.
 A Pancoast tumor may also cause shoulder pain.
 Mesothelioma
 Dull, aching pain in the anterior chest unchanged by
coughing or inspiration/expiration.
 In some cases, pleuritic pain may be present
 Breast Abscess
 Nipple pain, burning, itching, radiating pain toward the
chest wall, and redness around the nipple and areola, a
mass in the affected area of the breast, and fever.
 Breast Adenocarcinoma
 Localized, unilateral breast pain of an aching nature.
Symptoms may be aggravated by pressure to the breast
 Candida Breast Infection
 Nipple pain, burning, itching, radiating pain toward the
chest wall, and redness around the nipple and areola.
 Costochondritis
 “Aching” pain in the upper anterior thorax, either
centrally or in the parasternal region, episodically
worsened to a “sharp, jabbing pain” with activity,
sneezing, coughing, and deep breaths
 Cyclic Breast Pain
 Bilateral recurrent breast pain that may be aggravated
by movement and pressure but is not tender at a focal
point.
 Pain resolves after onset of menstruation.
 Delayed-Onset Muscle Soreness
 Pain in the upper thorax with occasional referral to the
upper extremities.
 Pain may be described as aching, burning, or pulling. This
type of muscle soreness is often preceded by an abrupt
increase in physical activity approximately 12 to 48 hours
prior to onset of pain.
 The symptoms usually occur in the muscles that were most
active during exercise.
 Dorsal Nerve Root Irritation
 Sharp, lancinating pain that starts in the back and shoots
through to the anterior chest in the midthoracic region.
 The pain is aggravated by any spinal movement,
coughing, and sneezing
 A history of previous back pain may be present.
 Sensory changes may be present as may be a description
of a burning sensation.
 This irritation may occur because of disk herniation,
osteophyte formation, degeneration of the intervertebral
disk space, tumor, tuberculosis, or osteomyelitis
 Fibrocystic Breast Disease
 lateral breast pain in one breast, tenderness, and
palpable mass.
 There is a focal region of pain at the site of the mass.
 Diagnosis is made by mammogram, ultrasonography,
and/or breast biopsy.
 Needle aspiration will remove the fluid and relieve the
pain, and aspirate fluid may be analyzed by a
pathologist to confirm the benign nature of this condition
 Fibromyalgia
 Pain in the anterior and posterior neck, upper chest, arms, lower back, and legs. Pain is described
as aching and burning, or as soreness and stiffness.
 Individuals will describe fatigue, difficulty sleeping, and pain increase with even mild activity.
 Some patients will also present with psychological dysfunctions such as depression and anxiety
disorders.
 Fibromyalgia is more common in women than men in a ratio of approximately 8:1. The prevalence
increases with age.
 Because laboratory tests and imaging are usually normal, patients are most commonly diagnosed
using the criteria established by the American College of Rheumatology.
 These criteria include widespread pain for at least 3 months, pain (not tenderness) to digital
palpation in 11 of 18 points, fatigue, insomnia, joint pain, headaches, and mood disorders.
 Sleep disorders and deficiencies in growth hormone, serotonin, and cortisol response have been
implicated in the pathogenesis, but the disease is still poorly understood. Clinical examination
confirms the diagnosis.
 Physical therapists may begin treatment, but should refer patient to a physician (most likely a
rheumatologist) to rule out autoimmune disease and to determine what other medical interventions
may be available
 Fracture of the Rib or Sternum
 Chest wall pain following blunt trauma.
 Pain may be worsened with trunk movements that move
the fracture site or when taking a deep breath.
 Typically, low-velocity impacts (ie, sports participation)
can cause unilateral and isolated rib fractures, whereas
high-velocity impacts (ie, deceleration against a steering
wheel during a motor vehicle accident) and crushes cause
more extensive, bilateral fractures that also may involve
the sternum.
 Galactocele
 Sometimes painful, unilateral, tender breast mass. Onset is gradual
and the patient will usually report a recent episode of breast-
feeding.
 Fever is not usually present.
 This is caused by a blocked duct and usually resolves spontaneously.
 Women who wear tight or restrictive clothing may be at increased
risk for this disorder.
 This is a diagnosis of exclusion, although needle aspiration may
reveal milky fluid, and mammography may identify a fluid in the
lesion.
 Mammography is usually reserved for individuals with recurrent
lesions.
 Herpes Zoster
 Unilateral, sharp, and shooting pain in the anterior chest
similar to that of myocardial infarction, accompanied by a
nodular skin rash several days after onset.
 Skin nodules are usually small, red, and oval.
 As the pathology progresses, the pain may change to a
burning nature.
 Individuals with this condition may have fever, malaise, or
sensory changes in the region of symptoms.
 Wrestlers sometimes develop infections on the thorax
because of skin trauma
 Iatrogenic Muscle Pain
 Generalized or specific region muscle pain or “soreness”
without apparent cause.
 Symptoms do not resolve as would be expected with
delayed-onset muscle soreness.
 Mastitis
 Unilateral pain in the breast, accompanied by fever and
flu-like symptoms.
 The affected breast will have an area of redness,
swelling, tenderness, and warmth.
 This occurs most commonly in women who are breast-
feeding and may be accompanied by visible breaks in the
skin.
 Mondor’s Disease
 Pain on one side of the anterior chest that is made worse
by deep inspiration.
 Individuals with this condition may describe a trauma to
this region that causes the superficial chest wall vein
rupture characteristic of this pathology
 Precordial Catch Syndrome
 Severe, sharp, non-radiating pain in the central chest at
rest or after mild exertion.
 This pain may last only a few seconds but may be
followed by a short period of residual ache.
 RHEUMATOID ARTHRITIS–LIKE
DISEASES
 Dermatomyositis
 Pain with movement in any direction and muscle tenderness, aching, and weakness.
 The weakness often results in increasing functional deficits particularly in tasks requiring the use of
proximal musculature
 This condition affects children and adults, but women more commonly than men. It is identified by a
blue-purple rash on the upper eyelids, red rash on the face and trunk, and erythema of the
knuckles.
 Scaly eruptions are also common.
 The rash may also be present on other areas of the body and may worsen with sun exposure.
Muscle weakness may be absent or may occur after the rash appears. Extramuscular symptoms
include fever, malaise, dysphagia, cardiac disturbances, pulmonary dysfunction, and subcutaneous
calcifications.
 It is associated with the presence of a malignancy in 20% of all cases. Other connective tissue
diseases may be also be present.
 Diagnosis is most commonly confirmed by the presence of an elevated serum creatine kinase level
and pathology findings on muscle biopsy.
 Needle electromyography may be useful to demonstrate affected muscles.
 Physical therapists should refer individuals suspected of having these conditions to a physician (most
likely a rheumatologist) for evaluation
 Inclusion Body Myositis
 Pain with movement in any direction and muscle tenderness,
aching, and weakness.
 The weakness often results in increasing functional deficits
particularly in tasks requiring the use of proximal musculature
 Polymyositis
 Pain with movement in any direction and muscle tenderness, aching, and weakness.
 The weakness often results in increasing functional deficits particularly in tasks
requiring the use of proximal musculature.
 This disease is rare and is predominantly a disease of adults.
 This disease is overdiagnoses in patients presenting with multiple regions of myalgia
and is the subject of considerable medical debate.
 Generalized proximal muscle weakness in multiple regions of the body is the most
common symptom.
 Dysphagia and facial weakness are uncommon. Extramuscular symptoms include
fever, malaise, dysphagia, cardiac disturbances, pulmonary dysfunction, and
subcutaneous calcifications.
 Other connective tissue diseases may be also be present.
 Elevated serum creatine kinase level and pathology findings on muscle biopsy
confirm the diagnosis. Needle electromyography may be useful to demonstrate
affected muscles.