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9: Chest Pain

CHIEF COMPLAINT

PATIENT image

Mr. W is a 56-year-old man who comes to your office with chest pain.

image What is the differential diagnosis of chest pain? How would you frame the differential?

CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

A patient with chest pain poses one of the most complicated diagnostic challenges. The differential diagnosis is extensive and includes diagnoses that can be imminently life-threatening. The initial pivotal points are the acuity of onset of the pain and the presence of vital sign abnormalities. Later in the evaluation, the presence of ECG or chest film abnormalities, symptoms consistent with aortic dissection, and the presence or absence of pleuritic pain (pain that worsens with inspiration) are important pivotal points. An algorithm to guide the consideration of the patient with chest pain is shown in Figure 9-1.

Figure 9-1.

Evaluation of the patient with chest pain.

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The differential diagnosis of chest pain is best remembered using an anatomic approach. Consideration needs to be given to the structures from the skin to the internal organs. The differential below is organized anatomically.

  1. Skin: Herpes zoster

  2. Breast

    1. Fibroadenomas

    2. Mastitis

    3. Gynecomastia

  3. Musculoskeletal

    1. Costochondritis

    2. Precordial catch syndrome

    3. Pectoral muscle strain

    4. Rib fracture

    5. Cervical or thoracic spondylosis (C4–T6)

    6. Myositis

  4. Esophageal

    1. Spasm

    2. Rupture

    3. Esophagitis

      1. Reflux

      2. Medication-related

    4. Neoplasm

  5. Gastrointestinal (GI)

    1. Peptic ulcer disease

    2. Gallbladder disease

    3. Liver abscess

    4. Subdiaphragmatic abscess

    5. Pancreatitis

  6. Pulmonary

    1. Pleura

      1. Pleural effusion

      2. Pneumonia

      3. Neoplasm

      4. Viral infections

      5. Pneumothorax

    2. Lung

      1. Neoplasm

      2. Pneumonia

    3. Pulmonary vasculature

      1. Pulmonary embolism

      2. Pulmonary hypertension

  7. Cardiac

    1. Pericarditis

    2. Myocarditis

    3. Myocardial ischemia (stable angina, myocardial infarction, or unstable angina)

  8. Vascular: Thoracic aortic aneurysm or aortic dissection

  9. Mediastinal structures

    1. Lymphoma

    2. Thymoma

  10. Psychiatric

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Mr. W has a history of well-controlled hypertension and diabetes. He has been having symptoms for the last 4 months. He feels squeezing, substernal pressure while climbing stairs to the elevated train he rides to work. The pressure resolves after about 5 minutes of rest. He also occasionally feels the sensation during stressful periods at work. It is occasionally associated with mild nausea and jaw pain. Medications are metformin, aspirin, and enalapril.

image At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?

RANKING THE DIFFERENTIAL DIAGNOSIS

Mr. W is a middle-aged man with chronic, nonpleuritic chest pain and risk factors for coronary artery disease (CAD). His symptoms are consistent with stable angina. The pivotal points in this case are the chronicity, exertional nature, and substernal location of the pain. Given the seriousness and prevalence of CAD, it must lead the differential diagnosis. Gastroesophageal reflux disease (GERD) and musculoskeletal disorders are common causes of chest pain that can mimic angina (exacerbated by activity, sensation of pressure) and thus should be considered. The chronicity of his symptoms ...

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