History taking in cardiology cont..
Chest pain is a common symptom of a variety of diseases. Developing a clear and thorough approach to chest pain is immensely important for your day to day practice and also for students for their assessments and exams. The spectrum of diseases producing chest pain range from innocuous conditions like muscle aches to life threatening myocardial infarction and aortic dissection.
Developing an approach to chest pain:
I will discuss in detail the approach which will be applicable for case presentation in exams and also for day to day practice.
The approach to chest pain can be divided into four steps
Step-1: this should include a thorough description of the symptom. Characterize the pain in the best possible detail
Step-2: localization of the pain to the different anatomic systems in the chest like – respiratory system, cardiovascular system, musculoskeletal system, gastrointestinal tract, hepato-pancreato-biliary system, neurological system.
Step-3: since we are mainly concerned with the cardiovascular system, the next step is localization of the chest pain to different cardiac structures – pericardium, coronary arteries, myocardium, endocardial structures and aorta.
Step-4: And finally etiology of chest pain.
A thorough understanding of each step is of paramount importance. At the end of history you should be able to form a list of etiologic differential diagnoses ranked according to priority.
Does this sound too much? Its not actually as you will discover as you read further.
Step-1: describing the chest pain
Describe the chest pain in the following headings
- Quality of pain – the common terms used to describe different types of chest pain are deep, boring, chest discomfort, tightness, heaviness, uneasiness, pricking, choking, sharp, shooting, ripping pain etc
- Location of pain- try to elicit the exact location by asking the patient to point to point to the site of maximum pain
- Radiation of pain
- Onset of pain- acute onset or insidious onset
- Tempo of progression
- Duration of symptoms
- Aggravating factors
- Relieving factors
- Positional variation in pain
- Any associated symptoms
- Other cardiac symptoms – shortness of breath, palpitation, fatigue, syncope, dizziness, cyanosis
- Respiratory symptoms- cough, expectoration, wheezing, hemoptysis, shortness of breath etc
- Gastrointestinal symptoms- nausea, vomiting, relation to food, dysphagia, odynophagia,
- Any neurological symptoms
- Any pain, redness or swelling at site of pain
Once this characterization part is over move to step-2
Step-2: Localization of pain to different organ systems:
The key to localization of the symptom to a particular system is the above characterization of pain. Below is a table of the salient features of each system.
|SYSTEM||SYNDROME||CLINICAL DESCRIPTION||KEY DISTINGUISHING FEATURES|
|Cardiac||Angina||Retrosternal chest pressure, burning, or heaviness; radiating occasionally to neck, jaw, epigastrium, shoulders, left arm||Precipitated by exercise, cold weather, or emotional stress; duration 2-10 min, relieved by rest or nitrates|
|Rest or unstable angina||Same as angina, but may be more severe||Typically <20 min; lower tolerance for exertion; crescendo pattern|
|Acute myocardial infarction||Same as angina, but may be more severe||Sudden onset, usually lasting ≥30 min; often associated with shortness of breath, weakness, nausea, vomiting|
|Pericarditis||Sharp, pleuritic pain aggravated by changes in position; highly variable duration||Pericardial friction rub|
|Vascular||Aortic dissection||Excruciating, ripping pain of sudden onset in anterior of chest, often radiating to back||Marked severity of unrelenting pain; usually occurs in setting of hypertension or underlying connective tissue disorder such as Marfan syndrome|
|Pulmonary embolism||Sudden onset of dyspnea and pain, usually pleuritic with pulmonary infarction||Dyspnea, tachypnea, tachycardia, signs of right heart failure|
|Pulmonary hypertension||Substernal chest pressure, exacerbated by exertion||Pain associated with dyspnea and signs of pulmonary hypertension|
|Pulmonary||Pleuritis and/or pneumonia||Pleuritic pain, usually brief, over involved area||Pain pleuritic and lateral to midline, associated with dyspnea|
|Tracheobronchitis||Burning discomfort in midline||Midline location, associated with coughing|
|Spontaneous pneumothorax||Sudden onset of unilateral pleuritic pain, with dyspnea||Abrupt onset of dyspnea and pain|
|Gastrointestinal||Esophageal reflux||Burning substernal and epigastric discomfort, 10-60 min in duration||Aggravated by large meal and postprandial recumbency; relieved by antacid|
|Peptic ulcer||Prolonged epigastric or substernal burning||Relieved by antacid or food|
|Gallbladder disease||Prolonged epigastric or right upper quadrant pain||Unprovoked or following meal|
|Pancreatitis||Prolonged, intense epigastric and substernal pain||Risk factors including alcohol, hypertriglyceridemia, medications|
|Musculoskeletal||Costochondritis||Sudden onset of intense fleeting pain||May be reproduced by pressure over affected joint; occasionally, swelling and inflammation over costochondral joint|
|Cervical disc disease||Sudden onset of fleeting pain||May be reproduced with movement of neck|
|Trauma or strain||Constant pain||Reproduced by palpation or movement of chest wall or arms|
|Infectious||Herpes zoster||Prolonged burning pain in dermatomal distribution||Vesicular rash, dermatomal distribution|
|Psychological||Panic disorder||Chest tightness or aching, often accompanied by dyspnea and lasting 30 minutes or more, unrelated to exertion or movement||Patient may have other evidence of emotional disorder|
This table provides a lot of information. Once you go through the table a list of differential diagnoses can be made and appropriate investigations ordered.
The next discussion is for case presentation in exams
Step-3: the above table also helps in localizing the cardiovascular structures causing the pain.
Step-4: Etiology of cardiovascular cause of chest pain:
Finally you have to think of the Etiology of the cardiac chest pain. Now we will examine the common etiologies of chest pain and try to differentiate them clinically.
- Coronary artery disease: there will be history of angina as described in the table
- Left ventricular outflow tract obstruction (LVOTO): the symptoms of LVOTO are remembered by the letters – ASD- Angina, Syncope and Dyspnea. RVOTO also has similar symptoms. They may have additional features of right heart failure like- peripheral edema, ascites, right upper quadrant pain, neck pulsations, cyanosis etc
- Mitral stenosis and less commonly mitral regurgitation can have chest pain. But the predominate symptoms in case of
- Mitral stenosis: dyspnea
- Mitral regurgitation: fatigue and palpitation
- Pulmonary arterial hypertension: can have angina. The predominant symptoms will be dyspnea, fatigue. Associated symptoms can be palpitation, syncope.
This will cover some of the common cardiac causes of chest pain for exam case presentation.
Conclusion: Chest pain is a common symptom with a wide spectrum of presentation. Attention to the details of history will help to narrow down the possible conditions giving rise to the chest pain.
Your comments, suggestions and corrections are most welcome and will greatly help me to improve my articles.