Chest Pain Origin Assessment
How do you differentiate chest pain that is of cardiac origin from musculoskeletal or pulmonary chest pain? Describe how you will prioritize assessment, diagnosis and treatment in collaboration with team.
Discussion 2: Assessment, Diagnosis, and Treatment of Chest Pain
Chest pain is a serious complaint among patients and accounts for one to two percent of the primary healthcare outpatient visits. The causes of chest pain can be cardiac and non-cardiac. There is a need to distinguish between benign and severe causes of chest pain using prognostic and diagnostic questions. Even though chest pain is usually connected to cardiovascular problems, it could have neurological, pulmonary, gastrointestinal, musculoskeletal, idiopathic, or psychogenic causes (Dunphy et al., 2019). Consequently, the chest pain originates from the coronary arteries, esophagus, stomach, or thorax bones and muscles.
If the patient’s pain is exertional and can be alleviated by resting, the source of the chest pain can either be the heart or chest’s musculoskeletal components. For instance, if a patient experiences chest pain when carrying a bag of groceries with his left arm only, then the musculoskeletal system is the probable culprit (Bickley et al. 2017). Also, tenderness in the pectoral muscle and costal cartilage suggest but, does not substantiate, that the chest pain has localized musculoskeletal origins. Furthermore, the causes associated with muscles and bones include broken or bruised ribs, soreness of the muscles from physical exertions, chronic pain syndrome, or compression fracture. Besides, patients with pulmonary embolism, pneumonia, pneumothorax, bronchospasm, and viral bronchitis could also have chest pains. However, they usually have a fever, hemoptysis, or productive cough. If the patient has vigorous or protracted coughing, it could experience chest pain resulting from periosteal trauma or intercostal muscle (Seller & Symons, 2017). There is also the presence of tenderness in the local chest wall. But, if chest pain is associated with coronary artery disease, the occurrence increases after age 35 and menopause in men and women, respectively. In persons up to 50 years old, chest pain happens more commonly in men, and then equally in both women and men aged above 50 years. While chest pain is acknowledged as the most common sign of heart problems, some individuals manifest other types of symptoms, either with or with no accompanying chest pain. The symptoms include chest pressure, arm, back, or jaw pain, lightheadedness, fatigue, dizziness, abdominal pain, nausea, shortness of breath, and pain during exertion.
The physician should thoroughly be familiar with the chest pain differential diagnosis taking into consideration catastrophic events lie acute coronary syndrome, pericarditis, esophageal rupture, aortic dissection, and pulmonary embolism. The clinician should comprehend that it is in the patient’s best interest not to disregard acute cardiac illness. It is also equally crucial that cardiac disease is not be erroneously diagnosed or concluded since the misdiagnosis might cause one to panic they have an underlying cardiac condition unsuitably. Thus, the physician should get an intensive health history and physical examination, precise assessment, and suitable treatment for patients. The patient history’s critical elements comprise an appraisal of the main indicators of heart disease, heart failure, chest pain, dyspnea, plus syncope (Dunphy et al., 2019). The physician should inquire about the patients across all age groups about exercise tolerance, especially if exercise can provoke some of the patient complaints. Furthermore, the patient’s history of the present illness with chest pain will mainly concentrate on the past medical history and personal cardiac risk factors for cardiovascular disease, smoking, elevated cholesterol, hypertension, and family history.
A complete analysis of chest pain symptoms includes quality, duration, location, relieving, aggravating factors, and associated symptoms. Notably, the moving pain, localized, and fleeting is seldom revealing severe cardiac pathology. Costochondritis is designated as localized, and it may be signified with the movements of the arm or pressing on the tenderness area. Contrastingly, the discomfort chest pain is characteristically described as turgid and retrosternal sensations, with radiation, heavy and burning sensations lasting between a minute and ten minutes. Exertional symptoms are more common in persons with fixed atherosclerotic lesions. In the assessment of persons with known angina pectoris, changes in the symptom pattern should be ascertained as it may designate an alteration in vessel patency like in accelerated atherosclerosis (McConaghy & Oza, 2013). It is crucial to determine whether the patient has had any prior investigation and treatment for chest pain. Finally, a comprehensive medical history should be taken, the use of nonsteroidal anti-inflammatory drugs leads to gastric pain owing to gastritis, gastric ulcers, and duodenitis.
A physical examination can aid in narrowing down the differential diagnosis. Patients experiencing chest pain can present acute shocks, like tension pneumothorax, massive PE, Cardiac tamponade, pancreatitis, cholecystitis, esophageal rupture, and ACS cardiogenic shock. The primary observations comprise blood pressure, temperature, heart rhythm, oxygen saturation, respiratory, and pulse rate. Several tests can be ordered to diagnose or eradicate heart-related problems as the cause (Seller & Symons, 2017). The tests include electrocardiogram, blood tests, chest X-ray, echocardiogram, MRI, stress tests, an angiogram. Moreover, the treatment plan of chest pain comprises medications, noninvasive procedures, or surgery, dependent on the causes and severity of the pain. The treatment plan for causes of chest pain that are related to the heart can include medications including nitroglycerin, cardiac catheterization, and coronary artery bypass grafting.
Finally, one of the clinical experience cases is an encounter with a patient with chest pain that was not continuous. Before the second visit, the patient had a similar chest pain episode as he had a burning sensation to his chest that felt like a lump in his throat. He was going to the Emergency room, where EGD revealed that the patient has gastroesophageal reflux disease. Following a successful treatment plan consisting of antacid and Pepcid AC, the patient has since improved. One of the main lessons is that the esophagus can be a source of chest pain that arises from Gastroesophageal reflux disease that occurs after the prolonged exposure to gastric acid due to impaired esophageal motility and excessive relaxation of the lower esophageal sphincter. It was a good learning experience to see how the patient described the chest pain related to gastrointestinal causes. Finally, I was able to aid in reviewing the patient’s history, conducting a physical exam, ordering the diagnostics, as well as prescribing the appropriate treatment plan, follow up, and referral.
References
Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.
McConaghy, J. R., & Oza, R. S. (January 01, 2013). Outpatient diagnosis of acute chest pain in adults. American Family Physician, 87, 3, 177-182.
Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.