pain diagnosis

How is chest pain diagnosed?

The key to diagnosis remains history. Learning about the nature of the pain will give the healthcare provider direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the care provider assess the probability of what potential diagnoses should be considered and which should be discarded.


Differential diagnosis is a thought process that healthcare providers use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential diagnoses may exist, and the healthcare provider will want to first consider those that are life-threatening. Tests to rule out heart attack, pulmonary embolus, or aortic dissection may not be necessary; when clinical skill and judgment may be all that is needed to consider or discard a diagnosis.


The patient may be asked a variety of questions to help the healthcare provider understand the patient's pain. Patients use different words to describe pain, and it is important that the healthcare provider get an accurate impression of the situation. The questions may also be asked in different ways.

Questions the doctor may ask about chest pain;

• When did the pain start?
  
• What is the quality of the pain?


• How long does the pain last?


• Does the pain come and go?


• What makes the pain better?


• What makes the pain worse?


• Does the pain radiate somewhere (move to another area of the body)?


• Has there been any preceding illness?


• Has there been any trauma?


• Have there been similar episodes of pain in the past?

Questions about the associated symptoms

• Is there shortness of breath?


• Fever or chills?


• Cough?


• Nausea or vomiting?


• Sweating?

Questions about risk factors for disease

Risk factors for heart disease

• Smoking


• High blood pressure


• High cholesterol


• Diabetes


• Family history

Risk factors for pulmonary embolus (blood clot to the lung)

• Prolonged inactivity such as bed rest, long car or airplane trips


• Recent surgery


• Fractures


• Birth control pill use (particularly if the patient smokes cigarettes)


• Cancer

Risk factors for aortic dissection

• High blood pressure


• Marfan syndrome


• Ehlers-Danlos syndrome


• Polycystic kidney disease


• Cocaine use


• Pregnancy

Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include:

Vital signs

• Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and


• Oxygen saturation (O2 sat)
  

Head and neck

• Looking for neck vein distension or bulging


• Listening over the carotid arteries for bruits (abnormal sounds) or murmurs
  

Chest wall

• Palpate for rib or muscle tenderness


• Look for rashes

Lungs

• Listen for abnormal lung sounds or decreased air entry

Heart

• Listen for abnormal heart sounds, murmurs or rubs (a friction sound made by two rough surfaces rubbing against each other, which may be seen with inflammation of the heart lining, called pericarditis)


• Listen for muffled heart tones

Abdomen

• Palpate for tenderness or masses


• Listen for bruits over the aorta

Extremities

• Feel for pulses

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