Chapter 013. Chest Discomfort (Part 4)

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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) 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 distress should lead to consideration of spontaneous pneumothorax, as well as pulmonary embolism. Such events may occur without a precipitating event in persons 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 cause inflammation of the pleura of the lung usually cause a sharp, knifelike pain that is aggravated 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 myocardial syndromes. Acid reflux typically causes a deep burning discomfort that may be exacerbated by alcohol, aspirin, or some foods; this discomfort is often relieved by antacid or other acid-reducing therapies. Acid reflux tends to be exacerbated by lying down and may be worse in early morning when the stomach is empty of food that might otherwise absorb gastric acid.
Esophageal spasm may occur in the presence or absence of acid reflux and leads to a squeezing pain indistinguishable from angina. Prompt relief of esophageal spasm is often provided by antianginal therapies such as sublingual nifedipine, further promoting confusion between these syndromes. Chest pain can also result from injury to the esophagus, such as a Mallory-Weiss tear caused by severe vomiting. Chest pain can result from diseases of the gastrointestinal tract below the diaphragm, including peptic ulcer disease, biliary disease, and pancreatitis. These conditions usually cause abdominal pain as well as chest discomfort; symptoms are not likely to be associated with exertion. The pain of ulcer disease typically occurs 60 to 90 min after meals, when postprandial acid production is no longer neutralized by food in the stomach. Cholecystitis usually causes a pain that is described as aching, occurring an hour or 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 cramps or by herpes zoster. Chest pain symptoms due to herpes zoster may occur before skin lesions are apparent.
Costochondral and chondrosternal syndromes are the most common causes of anterior chest musculoskeletal pain. Only occasionally are physical signs of costochondritis such as swelling, redness, and warmth (Tietze's syndrome) present. The pain of such syndromes is usually fleeting and sharp, but some patients experience a dull ache that lasts for hours. Direct pressure on the chondrosternal and costochondral junctions may reproduce the pain from these and other musculoskeletal syndromes. Arthritis of the shoulder and spine and bursitis may also cause chest pain. Some patients who have these conditions and myocardial ischemia blur and confuse symptoms of these syndromes. Emotional and Psychiatric Conditions As many as 10% of patients who present to emergency departments with acute chest discomfort have panic disorder or other emotional conditions. The symptoms in these populations are highly variable, but frequently the discomfort is described as visceral tightness or aching that lasts more than 30 min. Some patients offer other atypical descriptions, such as pain that is fleeting, sharp, and/or localized to a small region. The ECG in patients with emotional conditions may be difficult to interpret if hyperventilation causes ST-T-wave abnormalities. A careful history may elicit clues of depression, prior panic attacks, somatization, agoraphobia, or other phobias.