Chest pain

Signs and symptoms

Differential diagnosis

Cardiovascular

• Acute coronary syndrome
• * Stable or unstable angina
• * Myocardial infarction : People typically present with pressure or squeezing sensation over the chest in addition to sweating, nausea, vomiting, and weakness. Chest pain is more commonly associated with anterior infarction because of left ventricular impairment; inferior infarction is more commonly associated with nausea, vomiting, and excessive sweating due to irritation of vagus nerve; lateral infarction is associated with left arm pain.
• Prinzmetal's angina: Chest pain is caused by coronary vasospasm. It is more common in women younger than 50 years and has associations with tobacco, cocaine, or triptan use. People usually complain of chest pain at rest that is unrelated to stress or exertion. It is often relieved by cessation of the offending drug and the administration of nitrates or calcium channel blockers.
• Cocaine use: This condition is suspected when people with few risk factors for arteriosclerosis present with non-traumatic chest pain. Ingestion of cocaine can lead to vasoconstriction of coronary arteries, thus producing chest pain similar to heart attack. Symptoms can appear within one hour of cocaine use.
• Aortic stenosis: This condition occurs in individuals with underlying congenital bicuspid valve, aortic sclerosis, or a history of rheumatic fever. Chest pain usually happens during physical activity. Syncope is a late symptom. Signs and symptoms of heart failure may also be present. On auscultation, a loud ejection systolic murmur can be heard at the right second intercostal space with radiation to the carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
• Hypertrophic cardiomyopathy: It is the hypertrophy of interventricular septum that causes outflow obstruction of the left ventricle. Dyspnea and chest pain commonly occur during daily activities. Syncope may also occur. On physical examination, significant findings include: loud systolic murmur and palpable triple apical impulse due to a palpable presystolic fourth heart sound.
• Aortic dissection is characterized by severe chest pain that radiates the back. It is usually associated with Marfan's syndrome and hypertension. On examination, the murmur of aortic insufficiency can be heard with unequal radial pulses.
• Pericarditis: This condition can be the result of viral infection such as coxsackie virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial infarction. The chest pain is often pleuritic in nature which is aggravated when lying down and relieved on sitting forward, sometimes, accompanied by fever. On auscultation, pericardial friction rub can be heard.
• Cardiac tamponade: Cardiac tamponade occurs due to fluid accumulation in the pericardial space and typically presents with chest pain often accompanied by symptoms like dyspnea, hypotension, and pulsus paradoxus. Clinical signs include Beck's triad—hypotension, jugular venous distension, and muffled heart sounds.
• Arrhythmia: Atrial fibrillation and several other arrhythmias can cause chest pain.
• Myocarditis: Myocarditis often affects young men under 45, presenting with symptoms such as chest pain, rapid heartbeat, palpitations, difficulty breathing, and early heart failure signs. Approximately one-third experience sharp, squeezing chest pain, while nonspecific symptoms like fever, fatigue, and muscle aches may also occur. Common causes range from viral infections like Coxsackie and adenovirus to bacterial, fungal, chemical exposures, and autoimmune conditions such as lupus and rheumatoid arthritis.
• Mitral valve prolapse syndrome: Those affected are usually slim females presented with chest pain which is sharp in quality, localized at the apex, and relieved when lying down. Other symptoms include: shortness of breath, fatigue, and palpitations. On auscultation, midsystolic click followed by late systolic murmur can be heard, louder when person is in standing position.
• Aortic aneurysm: Aortic aneurysms, particularly when they rupture or dissect, cause sudden, severe chest or back pain often described as tearing or ripping. Thoracic aortic aneurysms are usually asymptomatic until they expand or rupture at which point they often have a >94% mortality rate'''.'''

  Respiratory

• Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and Bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. Chest pain usually happens during a strenuous activity or heavy exercise.
• Bronchitis: Bronchitis occurs due to inflammation of the bronchial tubes, often triggered by viral infections or irritants like smoke, leading to excessive mucus production and airway obstruction. Common symptoms include a productive cough, wheezing, mild chest discomfort, and fatigue.
• Pulmonary embolism: Common signs and symptoms are shortness of breath, pleuritic chest pain, blood in sputum during cough, and lower limb swelling. Risk factors includes: recent surgery, cancer, and bedridden state. Embolus source usually comes from venous thromboembolism.
• Pneumonia: Pneumonia arises from infections that cause inflammation and fluid accumulation in the alveoli of the lungs, with bacterial pathogens like Streptococcus pneumoniae being common culprits. Clinically, it manifests as fever, persistent cough, difficulty breathing, and pleuritic chest pain that worsens with deep breaths.
• Hemothorax: A hemothorax occurs from accumulation of blood in the pleural cavity, commonly due to trauma, vascular injury, or coagulopathies, which can disrupt lung expansion and oxygenation. Key symptoms include sharp chest pain, difficulty breathing, low blood pressure in severe cases, and diminished breath sounds accompanied by dullness to percussion over the affected area.
• Pneumothorax: Those who are at a higher risk of developing pneumothorax are tall, slim male smokers who have had underlying lung diseases such as emphysema. Those affected can have a sharp chest pain which radiates to the shoulder of the same side. Physical examination revealed absent breath sounds and hyperresonance on the affected side of the chest.
• Pleurisy: The pain is sharp, localized, and is frequently exacerbated with coughing or inspiration. It can be attributed to various etiologies including pulmonary embolism, pneumothorax, pericarditis, and viral pleurisy.
• Tuberculosis: Tuberculosis is caused by Mycobacterium tuberculosis, which primarily infects the lungs, leading to Granuloma formation as the immune system walls off the bacteria. Symptoms include chronic cough, fever, night sweats, weight loss, and pleuritic chest pain if the pleura is involved, often worsening with deep breaths or coughing.
• Tracheitis: Tracheitis, usually a bacterial driven inflammation of the trachea, which often narrows the airway. It can present as stridor and may cause respiratory distress symptoms like tachypnea, cyanosis, and hoarseness. Clinical symptoms include a dry, painful cough that worsens at night and may progress to a productive cough, fever, and retrosternal chest pain due to irritation of tracheal mucosa.
• Lung cancer: Hemoptysis, cough, dyspnea, chest pain, and other constitutional symptoms are commonly seen in lung cancer