Any of the structures within the chest are sensitive to pain except the lung parenchyma (tissue) and visceral pleura (not the parietal pleura - which is the cause of pleuritic pain). This makes chest pain a very difficult symptom to analyze as the list of causes are many.
I. Exclude causes with a CHARACTERISTIC clinical presentation
The best approach to chest pain is to first exclude the 'easier' causes which have a characteristic presentation. These include:
- Pleuritic chest pain: Pain arising from the pleura
characteristically increases with inspiration. This is seen in
pleurisy (inflammation of the pleura) but is also seen in
pericarditis (which is both pleuritic and positional). Sometimes
musculoskeletal causes (e.g. muscle strain) of chest pain can also
increase on inspiration.
- Positional chest pain: Pain arising from the pericardium
is characteristically positional. It increases on lying down
(supine). Pericarditis is both positional and pleuritic. Positional
chest pain is sometimes seen in both pleuritic and musculoskeletal
diseases, as patients describe being more comfortable by sleeping on
one side more than the other (the opposite side in pleuritic pain).
- Tender chest pain: This type of pain is characteristic of
chest wall disease such as costochondritis and other musculoskeletal
conditions. Touching the site of pain elicits tenderness. Musculoskeletal causes of chest pain are common especially if there is
a history of trauma, muscle strain or sprain.
- Dermatomal chest pain: Pain that arises spinal disease
that affects the nerve radicles causes a pain that affects a
specific dermatome on one side of the chest wall. Herpes zoster
infection also causes unilateral dermatomal chest pain.
- Referred chest pain from the neck: As described above,
this can be dermatomal in distribution. It is accompanied by a
history of neck pain or diseases of the cervical vertebrae such as
spondylosis. There may also be some tingling due to affection of the
- Chest pain associated with food intake: This characterizes pain that arises from gastrointestinal causes. The pain is usually in the epigastrium but may appear as central lower chest wall pain causing confusion. GERD, diffuse esophageal spasm (DES), peptic ulcer disease and gall bladder disease are amongst the most common causes.
II. Exclude the FOUR KILLER causes
After excluding the characteristic types, it's important to remember and carefully exclude the FOUR KILLERS of chest pain. These include:
- Ischemic heart disease (IHD):
Patients usually present with typical symptoms (central chest tightness
or heaviness which is brought on by exertion and relieved by rest. It
may radiate to the arms, the neck, jaw or teeth) in addition to the
presence of risk factors (old age, males more than females,
hypertension, diabetes, hypercholesterolemia, hypertension, smokers
as well as other risk
found to have IHD in 90% of cases. Patients with non-typical symptoms, who have no risk factors are found
to have IHD in
- Pulmonary embolism: Patients usually present with sudden
onset of dyspnea (in a matter of seconds) accompanied by chest pain.
They may have a risk factor for pulmonary embolism such as a history
- Pneumothorax: Tension pneumothorax is a medical
emergency. It presents with sudden onset of dyspnea and chest pain.
On examination there is tympanitic hyperresonance on percussion of
the chest wall.
- Ruptured aortic aneurysm: Ruptured aortic aneurysm may present with sudden onset of tearing chest pain which may radiate to the inter-scapular region. The patient may be known to have a history of aortic aneurysm.
III. Consider psychogenic chest pain
After excluding the above list of causes, it may be that the cause of the chest pain is psychological (such as hysterical).
This is more commonly seen in women and those with a history of psychological illness. However, this should be a diagnosis that is reached by exclusion.
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