Chest pain is a common symptom that can be clinically significant, so the first task in the diagnosis of chest pain is to exclude fatal diseases such as acute myocardial infarction, acute pulmonary embolism, aortic coarctation, tension pneumothorax, and acute abdominal disease. For patients with chest pain, it is best to find the cause.
I. Medical history
1. The onset is slow, the duration, the severity, the location and nature of pain, and the presence or absence of radiation.
2. Whether there is any relationship between chest pain and breathing, coughing, swallowing, physical activity, and emotional agitation.
3.Concomitant symptoms: presence of coughing, hemoptysis, dyspnea, dysphagia, acid reflux, heartburn, palpitations, forced body position, fever, swelling, etc.
4. Any similar episodes in the past, how they were treated, what drugs were used, and how responsive they were to drugs.
5.History of chest surgery, history of trauma.
6. Any cardiovascular disease risk factors.
Physical examination
1. Any abnormalities in the chest wall and local pressure pain, including skin, ribs, intercostal nerves, etc.
2. Any pathological signs of respiratory and circulatory system, and measurement of blood pressure of the extremities if necessary.
3. Any deformity, pressure pain and percussion pain in the spine.
Other examinations
1.Electrocardiogram, chest X-ray.
2.Echocardiogram.
3.Laboratory tests: blood routine, cardiac enzyme profile, D-dimer, etc.
4.X-ray of spine, MRI if necessary.
5.CT examination: including coronary artery CT angiography and CT pulmonary artery angiography, etc.
6.Coronary artery angiography.
7.Gastrointestinal system related examinations: such as 24-hour esophageal acid measurement, gastroscopy, abdominal plain film, abdominal ultrasound, etc.
IV. Differential diagnosis
1. Chest pain caused by chest wall diseases, with clear and limited localization, and mostly positive local findings, such as rash, redness, swelling, pressure pain, deformity, etc.
2.Spinal diseases compressing nerve roots, showing stabbing pain, electric shock pain, tearing pain, mostly episodic. It may extend to areas away from the irritation. Spinal examination may reveal deformity, pressure pain, percussion pain, and the pain occurs or worsens when the body is twisted or when holding heavy objects.
3.Posterior sternal pain is associated with swallowing and is seen in esophageal and intradistal diseases. If it is accompanied by heartburn and acid reflux, it is a typical clinical manifestation of reflux esophagitis.
4. Chest pain accompanied by coughing and aggravated by coughing and deep breathing indicates that the lesion has invaded the pleura, which is seen in pneumonia, tuberculosis, lung abscess and pleurisy.
5.Thoracic pain occurring during labor, full meal or emotional excitement should be considered as angina pectoris, myocardial infarction or aortic coarctation.
6.Sudden severe chest pain, except for trauma, is seen in acute myocardial infarction, aortic coarctation, acute pulmonary infarction, spontaneous pneumothorax, spontaneous esophageal rupture.
7, chest pain with shock, seen in acute myocardial infarction, acute pericardial compression, pulmonary infarction, spontaneous esophageal rupture. In aortic coarctation, there may be clinical manifestations of shock, but the blood pressure is not low, and the electrocardiogram and myocardial enzyme spectrum are normal. If the tumor ruptures, hemorrhagic shock occurs.
8.According to the site where chest pain occurs, it is helpful for diagnosis.
9.Anterior cardiac region, seen in angina pectoris, myocardial infarction, pericarditis.
10.Posterior sternal pain, seen in angina pectoris, acute myocardial infarction, pericarditis, mediastinal disease, esophageal disease.
11.Side chest pain, seen in chest wall, pleura, lung disease.
12.Back pain, in addition to spinal diseases, aortic entrapment can also occur.
13, with radiating pain, seen in angina pectoris, acute myocardial infarction, which can radiate to the left shoulder and left arm. And subdiaphragmatic abscess and liver abscess can radiate to the diseased side of the chest. And gallbladder disease can radiate to the right back under the scapula.
14.Chest pain with associated heart murmur can be seen in mitral valve prolapse, hypertrophic obstructive cardiomyopathy, aortic valve insufficiency and stenosis, aortic coarctation, aortic sinus aneurysm rupture.
15.The onset of chest pain accompanied by obvious dizziness, palpitations, panic and other neurological symptoms without obvious findings on objective examination is seen as panic attack.