The character of angina is tight and crushing, while the pain from aortic dissection has a tearing quality. Oesophageal reflux may be described as a burning pain, and peptic acid-related pain tends to be deep and gnawing.

Location

The pain from angina and oesophageal reflux may be located retrosternally, and they both can radiate to the jaw or down into the left arm. The pain from pericarditis may be centrally located and radiate to the shoulders (trapezius ridge pain). Pain from aortic dissection often radiates into the back and occasionally into the abdomen (depending on the extent of the dissection). Pulmonary pain can be located anywhere in the thorax.

Precipitating factors

Angina may be precipitated by effort, a defining characteristic. Other known precipitants of angina are emotion, food and cold weather. If angina occurs at rest for more than 20 min, it should be treated as a myocardial infarction until proven otherwise. Oesophageal reflux is often related to meals and precipitated by changes in posture, such as bending or lying. Pain originating from pericarditis and pulmonary origin is often pleuritic, i.e. worse on inspiration; however, musculoskeletal pain can also be worse on breathing due to movement of the thorax.

Relieving factors

Both oesophageal spasm and angina may be relieved by GTN, which relaxes smooth muscle. Antacids will relieve the pain of oesophageal reflux but not angina. The pain associated with pericarditis may be relieved by sitting forwards.

Trauma

A history of a blunt or stretching injury immediately suggests the underlying aetiology of chest wall tenderness and it is important to diagnose rib fractures that can result from more severe trauma. Pathological rib fractures that result from minor injuries may be due to bony metastasis or osteoporosis.

Emotion

Occasionally chest pain is a somatic manifestation of patients with depression or anxiety, but it is essential to exclude all organic causes before accepting depression or anxiety as the underlying cause. Moreover, a serious aetiology may co-exist.

Examination

Temperature

Pyrexia can occur with pneumonia, myocardial infarction, pericarditis and herpes zoster infection.

Pulse

Heart rate on its own is not discriminating, as pain invariably leads to tachycardia. However, palpating both upper and lower limb pulses may be useful. Occasionally peripheral pulses are absent in patients with aortic dissection.

JVP

The JVP is elevated with congestive cardiac failure and acute right ventricular failure, an occasional complication of inferior myocardial infarction and pulmonary embolism (when more than 60% of the pulmonary vascular supply is occluded).

Palpation of the chest

Chest wall tenderness would imply a musculoskeletal cause. The presence of unilateral tenderness confined to a single or adjacent group of dermatomes would suggest either central (vertebral or spinal origin) or peripheral nerve pathology (herpes zoster infection). The trachea deviates away from the side of a tension pneumothorax, and chest expansion is decreased on the same side for pneumonia and pneumothorax. Dullness to percussion will be noted in an area of consolidation with pneumonia and hyperresonance with pneumothorax (a difficult sign to interpret).

Auscultation of the chest

The unilateral absence of breath sounds is consistent with a pneumothorax; more localised loss occurs over an effusion. Bronchial breath sounds are audible over a segment of consolidation and sometimes above the level of an effusion. Localised areas of crepitations are audible with lobar pneumonia, whereas widespread crepitations suggest multilobar involvement or pulmonary oedema secondary to left ventricular failure (from myocardial infarction).

A friction rub may be auscultated with both pericardial and pleuritic disease, but only a pericardial rub will be present when the patient holds the breath.

Lower limbs

Hemiparesis can occur with aortic dissection, and a hot, swollen, tender calf or thigh may give a clue to an underlying deep vein thrombosis. Measurements of the mid-thigh or mid-calf circumference may demonstrate a larger circumference on the side of a DVT.