Chapter 8: Chest Pain Assessment & Diagnosis

Chest Pain Assessment & Diagnosis begins by prioritizing the identification of acute coronary syndrome, including myocardial infarction and ischemia, as well as catastrophic diagnoses like aortic dissection, pulmonary embolism, and pneumothorax. The content outlines the diagnostic reasoning process, focusing on gathering a precise history regarding pain quality, radiation patterns, onset, and duration, while accounting for risk factors such as hypertension, diabetes, smoking, and family history of coronary artery disease. A comprehensive physical examination guide is provided, covering the inspection of the skin for signs like cyanosis or herpes zoster, palpation of the chest wall to rule out costochondritis and rib fractures, and auscultation for adventitious lung sounds or cardiac abnormalities like murmurs, S3 and S4 gallops, and pericardial friction rubs. The summary explains the utility of diagnostic studies, including 12-lead ECG interpretation for ST-segment changes, cardiac biomarker analysis (troponin and CK-MB), D-dimer assays, and imaging modalities like spiral CT, echocardiography, and ventilation-perfusion scans. Extensive differential diagnoses are explored, contrasting the crushing pressure of myocardial infarction with the burning sensation of gastroesophageal reflux disease (GERD), the tearing pain of aortic dissection, and the pleuritic sharp pain associated with pneumonia or pulmonary embolism. The text also addresses non-cardiac causes such as esophageal spasm, cholecystitis, pancreatitis marked by elevated amylase and lipase, and musculoskeletal inflammation. Furthermore, it distinguishes pediatric presentations, where chest pain is rarely cardiac, from adult presentations, and discusses the influence of psychological factors like panic disorder and external triggers such as cocaine use.