NUR 643E Discussion Heaviness In Chest And Diaphoretic

Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes.

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Etiology

It sometimes is helpful to consider the different etiologies of pain. Visceral pain usually presents with a vague distribution pattern meaning that the patient is unlikely to localize the pain to a specific spot. When asking patients to point with one finger where they feel the pain, they will often move their hand around a larger area. Common descriptors of visceral pain are dull, deep, pressure and squeezing. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw or left arm. Symptoms like nausea and vomiting may also be a sign of visceral pain. Diaphragmatic irritation may refer to the shoulders as well. [1] Somatic pain is more specific than visceral pain, and patients will usually be able to point to a specific spot. Somatic pain is also less likely to refer to other parts of the body. Common descriptors of somatic pain are sharp, stabbing, and poking.

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Epidemiology

In the emergency department chest pain is the second most common complaint comprising approximately 5% of all emergency department visits. In evaluating for chest pain, the provider should always consider life-threatening causes of chest pain. These are listed below with approximate percent occurrence in patients presenting to the emergency department with chest pain based on a study by Fruerfaard et al. [2]

• Acute coronary syndrome (ACS), 31%
• Pulmonary embolism (PE), 2%
• Pneumothorax (PTX), unreported
• Pericardial tamponade, unreported (pericarditis 4%)
• Aortic dissection, 1%
• Esophageal perforation, unreported

Other common causes of chest pain with approximate percent occurrence in patients presenting to the emergency department with chest pain include:

• Gastrointestinal reflux disease, 30%
• Musculoskeletal causes, 28%
• Pneumonia/pleuritis, 2%
• Herpes zoster 0.5%
• Pericarditis, unreported

History and Physical

History

Like all workups, chest pain evaluation starts with taking a complete history. Start by getting a good understanding of their complaint.

• Onset: In addition to when the pain started, ask what the patient was doing when the pain started. Was the pain brought on by exertion or were they at rest?
• Location: Can the patient localize the pain with one finger or is it diffuse?
• Duration: How long did the pain last?
• Character: Let the patient describe the pain in his or her own words.
• Aggravation/alleviating factors: It is very important to find out what makes the pain worse. Is there an exertional component, is it associated with eating or breathing? Is there a positional component? Don’t forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried.
• Radiation: This may clue you into visceral pain.
• Timing: How many times do they experience this pain? For how long does it let up?

Ask about other symptoms such as:

• Shortness of breath
• Nausea and vomiting
• Fever
• Diaphoresis
• Cough
• Dyspepsia
• Edema
• Calf pain or swelling
• Recent illness

Evaluate for any of the following risk factors:

• ACS risks: prior myocardial infarction(MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD), and diabetes
• Pulmonary embolism (PE) risks: prior deep venous thrombosis (DVT) or PE, hormone use (including oral birth control), recent surgery, cancer, or periods of non-ambulation
• Recent gastrointestinal (GI) procedures like scopes
• Drug abuse (cocaine and methamphetamines)

Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.

Once you have thoroughly ruled out life-threatening causes, move on to other possibilities. Pneumonia should be considered in patients with a productive cough and/or recent upper respiratory infection (URI). Gastroesophageal reflux disease (GERD) is a common cause of chest pain so ask about any reflux symptoms. New exercise routines or recent trauma may help support a musculoskeletal cause. [2]

Physical

The physical exam should include:

• Full set of vitals including blood pressure (BP) measurements in both arms
• General appearance, noting diaphoresis and distress
• Skin exam for the presence of lesions (shingles)
• Neck exam for jugular venous distension (JVD), especially with inspiration (Kussmaul sign)
• Chest, palpate for reproducible pain and crepitus
• Heart exam
• Lung exam
• Abdominal exam
• Extremities for unilateral swelling, calf pain, edema, and symmetric, equal pulses