Chest Pains - Approach to a Patient with Chest Pain for the Long Case Examinations

Chest pain is a common exam question especially for the long case in undergraduate level exams. 

As in any scenario, usage of common sense is important and this will help you use time more effectively in the 60 mins designated for the long case exam. 

Differential diagnoses will depend on the anatomical location of the chest pain:

Skin:

Herpes zoster

• Fever, rash (usually in dermatomal location), history of varicella zoster infection, enquire about immune suppressed states: DM, malignancies, chronic steroid therapies or immune suppressive therapies 

Muscle:

Hematoma or soft tissue injury 

• history of chest wall trauma 
• Signs of external injuries: bruises, abrasions, deformities 
• Tender on palpation

Bone:

Costochondritis 

• recent exertion involving chest wall movement 
• Pain aggravated by thoracic wall movements (leaning forwards or backwards, rotatory movements, breathing in/ out movements)

Rib/ sternal fractures

• recent trauma to chest wall
• Chest wall deformities or signs of external injuries
• Chest spring will be positive over the fracture site 

Lung:

Pneumonia

• fever, cough, dyspnoea 
• Chest pain is usually described as pleuritic in nature nature 
• Usually associated with bronchial breathing and reduced breath sounds with coarse creps over the pain area 

Pneumothorax

• history of fever, cough, dyspnoea preceding or concurrent with pain onset 
• chest pain is usually described as sharp and sudden in onset for spontaneous pneumothorax
• history of recent chest wall trauma 
• history of pneumothorax 
• History of chronic lung disease 
• Look for chest tube scars or thoracotomy scars 
• Tall stature with long limbs suggestive of Marfanoid feature

Empyema

• Usually will have associated high grade fever, cough, dyspnoea
• Cough productive of purulent or blood stained sputum 
• Usually unwell appearance (septic looking)
• Chest pains due to empyema are usually pleuritic in nature
• Reduced chest expansion over the pain site 
• Reduced breath sounds with pleural effusion like findings 

Pleural effusion/ hemothorax

• similar to empyema except patient may be less septic looking on presentation
• the complaint may be more of dyspnoea or chest tightness as compared to chest pain
• may have other features of fluid overload: congestive heart failure, nephrotic syndrome, liver cirrhosis 
• Recent Chest wall trauma with evidence of external chest wall injury e.g. bruises, chest wall deformities, positive chest spring on palpation

Heart:

Angina

• pressing or crushing retrosternal chest pains (usually left sided) with typical radiation to i psi lateral shoulder or upper limbs and neck with associated diaphoresis, nausea, vomiting with/without syncope 
• History of similar attacks, or history of exertional angina 
• Risk factors: Age, family history of coronary artery disease, cigarette smoking, alcohol, DM, HPT, dyslipidemia, CKD

Dissecting aneurysm 

• usually present with back pains
• described as tearing pain
• History of high BP
• Check discrepancy in UL pulses
• Look for Marfanoid features 
• Look for new onset aortic valve murmurs
• Patient usually unwell 

Gastrointestinal tract:

GERD

• burning type retrosternal chest pains 
• May originate from epigastric region and extend superiorly to the throat 
• Assoc with acid or water brash
• May or may not have hoarseness or voice 
• Preceding heavy meals, spicy or oily foods 
• Usually symptoms have been ongoing for a long time 

FB 

• ask about bony fish meals or accidental or deliberate swallowing of any foreign bodies recently (if yes, you may need to explore suicidal tendencies and major depression). 

Spine:

Radiculopathies

• pain is usually circumferential ie radiating from the back around the sides to the front of the thorax. It is important to clarify this with patient so they may give you a clear description with regards to the nature and origin of the pain (on a personal note, I have encountered a case that was referred for chest pains suspecting to be unstable angina only to discover that the pain is actually from a collapsed thoracic vertebra due to TB spondylitis causing nerve root compression of the exiting thoracic spinal nerve). Radiculopathies can be caused by compression of the exiting spinal nerve root by a prolapsed intervertebral disc, a spinal cord tumour, paraspinal abscess or a collapsed vertebra as mentioned above, etc
• This type of pain may be aggravated by certain manouvres eg coughing, straining etc. 

Psychiatry:

Anxiety

• chest pains can be felt like a central anterior chest tightness sensation when experiencing a panic attack. It is usually accompanied by other supporting symptoms like feeling extreme fear, light headedness, palpitations, hand tremors, and the patient may or may not have a clear precipitating event or stressor. 

Major depression

• A depressed person may have multiple psychosomatic complaints. Pain may not necessarily be limited to the chest. Pain may also affect other body parts. Enquire about other depressive symptoms e.g. low mood, suicidal ideations, anhedonia, anorexia, etc. 

The list of chest pain aetiology mentioned above may seemed a lot and you may wonder if you will ever have time to explore each differential within the 60 min time frame. This is a valid concern. Therefore you need to be selective and use common sense and try narrow down the differentials based on the patient in front of you. As the clerking progresses, you’ll be able to gain more information to help you cross off the differentials one by one quickly. 

Lastly, practice makes perfect. So go out there and clerk many cases of dyspnoea. There are many such cases in the medical wards as it is a common presenting complaint. Happy learning. 

CCE.