Chapter 013. Chest Discomfort (Part 4)

Pulmonary Embolism(See also Chap. 256) Chest pain due to pulmonary embolism is believed to be due to distention of the pulmonary artery or infarction of a segment of the lung adjacent to the pleura.Massive pulmonary emboli may lead to substernal pain that is suggestive of acute myocardial infarction. More commonly, smaller emboli lead to focal pulmonary infarctions that cause pain that is lateral and pleuritic. Associated symptoms include dyspnea and, occasionally, hemoptysis. Tachycardia is usually present. Although not always present, certain characteristic ECG changes can support the diagnosis.Pneumothorax(See also Chap. 257) Sudden onset of pleuritic chest pain and respiratory...
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Chapter 013. Chest Discomfort (Part 4) Chapter 013. Chest Discomfort (Part 4) Pulmonary Embolism (See also Chap. 256) Chest pain due to pulmonary embolism is believed tobe due to distention of the pulmonary artery or infarction of a segment of the lungadjacent to the pleura. Massive pulmonary emboli may lead to substernal pain that is suggestive ofacute myocardial infarction. More commonly, smaller emboli lead to focalpulmonary infarctions that cause pain that is lateral and pleuritic. Associatedsymptoms include dyspnea and, occasionally, hemoptysis. Tachycardia is usuallypresent. Although not always present, certain characteristic ECG changes cansupport the diagnosis. Pneumothorax (See also Chap. 257) Sudden onset of pleuritic chest pain and respiratorydistress should lead to consideration of spontaneous pneumothorax, as well aspulmonary embolism. Such events may occur without a precipitating event inpersons without lung disease, or as a consequence of underlying lung disorders. Pneumonia or Pleuritis (See also Chaps. 251 and 257) Lung diseases that damage and causeinflammation of the pleura of the lung usually cause a sharp, knifelike pain that isaggravated by inspiration or coughing. Gastrointestinal Conditions (See also Chap. 286) Esophageal pain from acid reflux from the stomach,spasm, obstruction, or injury can be difficult to discern from myocardialsyndromes. Acid reflux typically causes a deep burning discomfort that may beexacerbated by alcohol, aspirin, or some foods; this discomfort is often relieved byantacid or other acid-reducing therapies. Acid reflux tends to be exacerbated bylying down and may be worse in early morning when the stomach is empty offood that might otherwise absorb gastric acid. Esophageal spasm may occur in the presence or absence of acid reflux andleads to a squeezing pain indistinguishable from angina. Prompt relief ofesophageal spasm is often provided by antianginal therapies such as sublingualnifedipine, further promoting confusion between these syndromes. Chest pain canalso result from injury to the esophagus, such as a Mallory-Weiss tear caused bysevere vomiting. Chest pain can result from diseases of the gastrointestinal tract below thediaphragm, including peptic ulcer disease, biliary disease, and pancreatitis. Theseconditions usually cause abdominal pain as well as chest discomfort; symptomsare not likely to be associated with exertion. The pain of ulcer disease typically occurs 60 to 90 min after meals, whenpostprandial acid production is no longer neutralized by food in the stomach.Cholecystitis usually causes a pain that is described as aching, occurring an houror more after meals. Neuromusculoskeletal Conditions Cervical disk disease can cause chest pain by compression of nerve roots.Pain in a dermatomal distribution can also be caused by intercostal muscle crampsor by herpes zoster. Chest pain symptoms due to herpes zoster may occur beforeskin lesions are apparent. Costochondral and chondrosternal syndromes are the most common causesof anterior chest musculoskeletal pain. Only occasionally are physical signs ofcostochondritis such as swelling, redness, and warmth (Tietzes syndrome) present.The pain of such syndromes is usually fleeting and sharp, but some patientsexperience a dull ache that lasts for hours. Direct pressure on the chondrosternaland costochondral junctions may reproduce the pain from these and othermusculoskeletal syndromes. Arthritis of the shoulder and spine and bursitis mayalso cause chest pain. Some patients who have these conditions and myocardialischemia blur and confuse symptoms of these syndromes. Emotional and Psychiatric Conditions As many as 10% of patients who present to emergency departments withacute chest discomfort have panic disorder or other emotional conditions. Thesymptoms in these populations are highly variable, but frequently the discomfort isdescribed as visceral tightness or aching that lasts more than 30 min. Somepatients offer other atypical descriptions, such as pain that is fleeting, sharp, and/orlocalized to a small region. The ECG in patients with emotional conditions may be difficult to interpretif hyperventilation causes ST-T-wave abnormalities. A careful history may elicitclues of depression, prior panic attacks, somatization, agoraphobia, or otherphobias.