For a patient like Brian, it is important to include a cardiac cause on your list of differential diagnoses. A cardiac event is a must not miss diagnosis and should be evaluated in any patient complaining of chest pain with risk factors like age, other high-risk health conditions or event history like an onset of symptoms during exertion.
Brian’s evaluation seems to be pointing away from a cardiac condition, so what other causes of chest pain can an EMS provider evaluate?
1. Trauma
When approaching your patient, keep an eye out for possible mechanisms of injury. Medical complaints like chest or abdominal pain may actually be the result of a traumatic injury. Without losing sight of the must not miss diagnoses, consider causes based on the patient’s surroundings and the narrative of what led up to the onset of symptoms.
A focused physical exam can produce findings which help confirm or refute a working diagnosis of chest wall trauma. Pay special attention to how the pain changes – if at all with palpation, movement and inspiration. Also be on the lookout for crepitus or obvious chest wall deformity which could indicate a traumatic mechanism.
In Brian’s case, he was working on a ladder, so a fall would be high on the list of concerns for mechanism. Brian denies a fall, however, or any other trauma so you are able to rule this out as a cause of his presentation.
2. Costochondritis
The ribs are connected to the sternum at the costosternal joint with connective tissue called the costal cartilage. As you may be able to tell from the name, costochondritis is an inflammation of the costal cartilage. This condition general presents abruptly and is associated with pain near the sternum.
As costochondritis is the swelling of a physical structure, pain can be expected to increase when palpated or when the patient moves in a way which aggravates the inflamed tissue. Asking the patient to take a deep breath (which expands the rib cage and moves the costal cartilage) or to lift the arms may provide confirmation of a suspicion of costochondritis.
This condition may be caused by physical damage (like heavy lifting or overstretching) but can also be the result of other structural complications, like arthritis.
In Brian’s case, the fact that his symptoms increase with palpation and movement place costochondritis high on the list of suspected diagnoses. It would be beneficial ask some follow-up questions about his normal level of physical activity, his activity today and whether he has been reaching or straining while decorating the gazebo.
3. Gastric reflux
As the name implies, gastric reflux is a condition which occurs when the contents of the stomach – which have a low, or acidic pH – move up into the esophagus. This condition can manifest as heartburn, but over time, as the esophagus is more regularly exposed to acid from the stomach, the lining can erode and the condition may present with sharp chest pain.
Like the other conditions discussed in this article, suspected gastric reflux patients should still be evaluated for a potential cardiac cause of their symptoms. One way to differentiate gastric reflux is a history of gastric esophageal reflux disease (GERD) or an onset of symptoms after eating. It is unlikely that GERD will present acutely with chest pain without a previous history of heartburn or other symptoms.
In order to determine Brian’s risk for GERD, ask further questions about his medical history and whether he has eaten recently. Additionally consider GERD based on risk factors like obesity, hiatal hernia or smoking. In this instance, Brian does not have risk factors for GERD and does not regularly experience heartburn symptoms.
4. Anxiety
EMS providers may be quick to assume that chest pain is caused by anxiety, particularly based on a patient’s history of previous anxiety attacks. It is important to note, however, that feeling anxious may be a response to an evolving cardiac event and it should never be assumed that anxiety is the underlying cause of the patient’s symptoms. On the contrary, it is appropriate to assume that anxiety is a symptom of an underlying cardiac condition until proven otherwise.
To better understand chest pain resulting from anxiety, it may help to think about why a cardiac event causes chest pain. Often, symptoms of cardiac chest pain are a result of increased oxygen demand by the heart muscle and may be caused by exertion or an arterial blockage. The pain is mostly constant, but may change the level of exertion. By contrast, anxiety-related chest pain often occurs at rest, is sharp and localized, and is momentary. Remember, however, that these are guidelines to assist you in building a differential diagnosis. A patient with chest pain should always be worked up for a possible cardiac cause as well.
5. Pleuritis
The lungs are surrounded by a membranous sac known as the pleura. There are two layers of membrane, with the lungs being covered by the visceral pleura and the chest wall being lined by the parietal pleura. The space between these two layers is known as the pleural cavity. Downward movement of the diaphragm creates negative pressure in the pleural cavity, which causes the lungs to expand and fill with air. As the name suggests, pleuritis (also known as pleurisy) is an inflammation of one or both layers of the pleura.
The pain from pleuritis is a result of the inflamed tissues rubbing together during breathing. Patients often describe the pain as sharp and increasing with inspiration, and may also complain of shortness of breath. The EMS provider may also note a rubbing sound during auscultation of lung sounds. Pleurisy is frequently caused by an infection, though may be caused by trauma as well.
Case resolution
Given Brian’s recent history of exertion and possibly overstretching while decorating the gazebo and his clear ECG, you and your partner strongly suspect that he is suffering from costochondritis brought on by overuse. With Brian’s age and history of high blood pressure, however, you elect to administer 324 mg of aspirin and recommend transport to the hospital.
Upon arrival, Brian is worked up for cardiac causes and all his tests come back clear. He is placed on activity restriction for a week and discharged home.
