Case 55

A 58-Year-Old Male With Chest Pain

Seth Politano

A 58-year-old male with a history of type 2 diabetes mellitus and hypothyroidism presents with a chief complaint of 2 days of intermittent chest pain.

What do you consider in your differential diagnosis of the chest pain in this patient?

A broad differential diagnosis should be undertaken with a chief complaint of chest pain (see Table 55.1). Particular attention should always be focused first toward life-threatening causes of chest pain, then other serious (but not immediately life-threatening) causes, then finally less ominous causes.

TABLE 55.1

Causes of Chest Pain (Potentially Life Threatening in Bold)

Cardiac

• Coronary disease (stable angina, vasospasm and vasculitis, coronary dissection infarction/ischemia with acute coronary syndromes)

• Cardiac tamponade

• Pericarditis

• Pericardial effusion

• Congestive heart failure, stress cardiomyopathy

• Myocarditis

• Valvular diseases (notably AS and MVP)

Pulmonary and Vascular

Gastrointestinal

• Esophageal rupture, esophagitis (erosive and infectious), esophageal spasm, achalasia, esophageal foreign body, esophageal diverticulum

• Gastroesophageal reflux disease

• Peptic ulcer disease, gastric obstruction, gastric malignancy

• Biliary stone diseases

• Pancreatitis

Musculoskeletal

• Costochondritis

• Muscular strain (esp. intercostal and pectoralis)

• Bursitis

• Rib fracture

• Referred cervical pain

Other

• Mediastinal masses (lymphoma, thymoma, teratoma)

• Psychiatric diseases (anxiety, panic disorder, somatization, malingering)

• Herpes zoster

• Chronic pain

What other historical elements can you use to elicit the history in a patient with chest pain?

With some of the life-threatening causes of chest pain, it is important to note that “pain” might not be the patient’s chief complaint. Patients often describe a stabbing, crushing, pressurelike, or tearing sensation. Therefore, sometimes using alternate words to ask a history, including “chest discomfort,” may be useful. Asking the patient if he or she has current chest pain is helpful for triage. Always obtain the usual elements, including prior events, onset/timing, location, severity, intensity, and alleviating and aggravating factors, as well as baseline functional status and exercise capability/limitations. It is important to undertake a complete medication history, family history, and social history and to elicit historical evidence of features that are characteristic for life-threatening causes of chest pain. Table 55.2 lists historical features of life-threatening causes of chest pain.

TABLE 55.2

Historical Features of Life-Threatening Causes of Chest Pain

Condition	Clinical Hints/Findings
Myocardial Infarction/Ischemia	Prior history, risk factors, location in the retrosternal/left side, worse with exertion, alleviated with rest or nitroglycerin.
Aortic Dissection	Severe tearing pain radiating to back. May also present with strokelike symptoms (i.e., weakness in lower extremities). Can also present with symptoms from complications, including pleural effusion and ischemia.
Pneumothorax	Sudden dyspnea and chest pain that is pleuritic in nature.
Cardiac Tamponade	Shortness of breath, weight loss (in a patient with malignancy-associated tamponade), fevers (in a patient with infectious or autoimmune disease-associated tamponade)
Pulmonary Embolism	Sudden dyspnea and chest pain that is pleuritic in nature. May have nonproductive or productive cough with hemoptysis. Risk factors include immobility, malignancy, smoking, oral contraceptive pills (OCPs), and inherited thrombophilias.
Esophageal Rupture	Sudden tearing pain. Recent straining, coughing, ingestion of caustic substances. History of reflux, carcinoma. Patients may also have back pain, referred shoulder pain, or abdominal pain.

After asking the patient salient features of conditions that are life-threatening, one can then investigate other causes of chest pain. A general review of systems will oftentimes elicit the relevant symptoms seen in these disorders. Specific questions to ask include those related to fever, weight loss, cough, edema, abdominal pain, food association, joint pain, rash, weakness in extremities, and psychiatric screening.

The patient indicates he has never had this chest pain before. He was mowing his lawn when the chest pain first occurred. He rates the pain as 6 to 8 out of 10, lasting a few minutes at a time, with at least five episodes before presentation. He says the pain is pressurelike and points to his sternum when describing the area of the pain. It is exacerbated by walking around his home and improves when resting. It is nonradiating in nature. He takes metformin 500 mg twice a day and levothyroxine 25 mcg daily. He has a 30-pack-year smoking history and uses no illicit drugs or alcohol. He is an only child. His mother and father are both alive, in their 80s, and both have hypertension. He denies fever, cough, joint pain, or weight changes.

What physical exam clues can you use with a chief complaint of chest pain?

Table 55.3 lists physical exam findings with select causes of chest pain.

Physical exam reveals a blood pressure of 148/92 mm Hg, with a pulse rate of 82/min. He is afebrile and his oxygen saturation is 97% on room air. He has no jugular venous distension, and his pulse rate is regular with no murmurs or rubs appreciated. Lung exam reveals normal breath sounds with no adventitious features. There is no abdominal pain, lower extremity edema, or rashes.

TABLE 55.3

Physical Exam Findings With Select Causes of Chest Pain

Condition	Clinical Hints/Findings
Myocardial Infarction/Ischemia	May have S3 (as seen in patients with acute heart failure) or S4 (as seen in patients with underlying coronary artery disease or hypertension) on exam. Murmur from onset of valvular disease or wall rupture. May also present with signs of low-output (hypotension, altered mental status) or volume overload (crackles, jugular venous distention, edema).
Aortic Dissection	Blood pressure difference in arms, murmur of aortic insufficiency, objective weakness in lower extremities, decreased pulses in lower extremities. Complications include hypotension, and exam findings consistent with pleural effusion and ischemia.
Pneumothorax	Decreased breath sounds, hyperresonance to percussion. Can see tracheal deviation with tension pneumothorax.
Cardiac Tamponade	Jugular distention, decreased breath sounds, hypotension, pulsus paradoxus.
Pulmonary Embolism	Tachycardia, tachypnea, hypoxia. Can have signs of deep vein thrombosis (DVT) and pleural effusion. Loud P2, fixed split S2.
Esophageal Rupture	Tachycardia, palpable subcutaneous emphysema, Hamman’s sign (audible crunch with heart sounds).
Pulmonary Hypertension	Loud P2, fixed split S2, heave, eventual right-sided heart failure (jugular venous distention, pulsatile liver, edema).
Congestive Heart Failure	Jugular venous distention, hepatojugular reflux, S3, S4, crackles, exam evidence of pleural effusion, may hear wheezing, pulsatile liver/hepatomegaly/ascites, dependent edema, pulsus alternans.
Pericarditis	Friction rub. May be tachycardic and febrile. Lymph node, joint exam, and skin exam may reflect causes (i.e., autoimmune diseases, infection, malignancy, uremia). Kussmaul’s sign (increased jugular venous distention or lack of decrease with inspiration) if constrictive.
Pneumonia	Fever, bronchial breath sounds, rhonchi, dullness to percussion, friction rub, signs of effusion.
Aortic Stenosis	Lack of normal carotid upstroke, systolic crescendo–decrescendo murmur which is loudest at the right upper sternal border that radiates to supraclavicular/carotid region. S4 may be present, and heart sounds may be paradoxically split or reveal the absence of A2 heart sounds.

Does this patient have angina?

The definition of angina is chest pain or discomfort that may be pressurelike, a sensation of fullness or squeezing; it can be felt in the chest, jaw, shoulder, back, or arm. The pain is usually less than 5 minutes in duration. In a patient presenting with chest pain, and when angina is suspected, it is useful to classify the chest pain into anginal categories depending on historical information (see Table 55.4).

Step 2/3

Clinical Pearl

Chest pain can be atypical in female patients or in those with diabetes. Women often complain of epigastric pain when presenting with angina. Other symptoms commonly seen with underlying coronary artery disease (CAD) including fatigue, diaphoresis, dizziness, dyspnea, nausea/emesis, and lightheadedness/syncope. Even some patients with underlying coronary disease or an acute cardiac event may present with atypical chest pain or even noncardiac chest pain.

TABLE 55.4

Anginal Classification

Components
1. Location and duration: retrocardiac or substernal 2. Aggravating factors: exertion or emotional stress 3. Alleviating factors: rest or nitroglycerin
Typical: 3/3 components	Atypical: 2/3 components	Noncardiac: 0-1/3 components