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DIFFERENTIAL FOR CHEST PAIN

There are various causes of chest pain, both cardiac and non cardiac.  The associated symptoms are useful in determining the possible etiology of the pain and doing the appropriate test to diagnose it.

Anginal pain is substernal, brought on by exertion and is relieved by rest or nitroglycerin. It is brief, typically lasting 5-15 minutes. If the patient has a myocardial infarction, the pain is likely to be accompanied by diaphoresis. The pain may radiate to both arms and the patient may have low blood pressure. Both require an EKG for diagnosis and a myocardial infarction is a medical emergency. If the patient has a ripping or tearing pain and pulse abnormalities, they may have aortic dissection.

Chest pain can also be caused by pericarditis, which may follow a viral illness. Chest pain in pericarditis radiates to the back, neck or shoulders and often worsens when the patient inhales. It is improves by leaning forward.

Non cardiac causes of chest pain include pulmonary embolism, pneumothorax and pneumonia. Pulmonary embolism causes a sudden onset of pleuritic chest pain. Associated symptoms are fatigue, dyspnea, fainting, spitting up blood and cardiac arrest. Pneumothorax can cause pleuritic, sharp pain, usually accompanied by shortness of breath. Pneumonia pain is usually accompanied by fever, cough, altered breath sounds, wheezing and rales.

Non emergency chest pain can be caused by gastrointestinal condition such as reflux, esophageal spasm or peptic ulcer. In the case of reflux, the patient may feel food moving upward from the stomach.  The discomfort is worse after eating and when reclining. Chest wall pain is sharp, localized and worsens with movement. Patients may have a history of rheumatoid arthritis or osteoarthritis. The pain is also reproducible on palpation.

Chest pain can also be induced by drugs such as cocaine. However, patients are not likely to reveal a history of illicit drug abuse and may need to be tested.

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