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When Is Chest Pain Something Else?

Chest pain is common...and complex. How do you know when it's serious (and when it's not)? House Call Doctor is on the case.

By
Sanaz Majd, MD,
Episode #183

Chest pain is by far is one of most frequently asked questions that I receive from listeners. Unfortunately, it's one that isn't so easily addressed in an email. 

Chest pain can be complex, with a seemingly endless list of causes. To get to the root cause of chest pain usually requires lengthy questioning by your doctor, along with a solid physical exam and very likely tests. 

Most people just want to know if what they are experiencing is something serious.  Is it something that can wait, or will it render you with one foot in the grave if you don’t call 911 now?  This one symptom causes more alarm than any other, for understandable reasons – heart disease is the number one killer of men and women in the United States.  Chest pain is the classic symptom of a heart attack.  Who wants to risk that?

In order to illustrate what truly goes through my mind as a doctor when evaluating a patient with chest pain, let’s follow the story of a patient named Chelsea, a 39-year-old woman who comes to see me in the clinic.

The Patient History

I want to know everything about Chelsea’s chest pain…down to the nitty gritty.  That means I need to review not only her medical history and diagnoses in her chart, but also her current symptoms and details.  After all, chest pain is something most doctors take very seriously – I want to know as much as I possibly can about Chelsea’s symptoms.

I’ve known Chelsea as a patient for 4 years now. She’s a young woman with a thyroid disorder that is under control with medication. She is also somewhat overweight, with a BMI of 27.  Otherwise, she’s healthy. But given her symptoms, I want to isolate her risk factors for heart disease, even though she’s only 39. So I ask Chelease the following questions:

  1. Is she a smoker or has ever been? (No)

  2. Does she have diabetes? (No)

  3. Does she have high blood pressure, or hypertension? (No)

  4. Is there early first degree family history of heart disease - meaning do her parents or siblings have heart disease? (No, only her grandfather who had a stroke at age 92)

  5. Does she have high cholesterol? (It was mildly elevated at her last blood test but nothing that necessitated medication)

As mentioned before, Chelsea is overweight and lives a rather sedentary life as a computer programmer and young mother of 3 children.  She has a difficult time maintaining a fitness regimen and as a result has put on about 20 pounds of weight in the last 2 years.

The Current Symptoms 

When discussing Chelsea’s chest pain, she reveals that she’s been experiencing this pain for about 2 weeks.  Here’s what I need to know and what I discern from our conversation. There's a useful mneumonic that doctors follow when evaluating chest pain. It's called PQRST:

  • P (Provocation):  Did the pain happen at rest or during exertion? For Chelsea, sleeping seems to provoke or trigger the pain.

  • Q (Quality of pain):  Is it an ache, burning, sharpness, or a sense of pressure? How is the quality of the pain described? Chelsea describes her as an “ache.”

  • R (Region of location and radiation):  Where is the pain located? Is it right in the center of the chest? Or on one side? For Chelsea there is no radiation of pain to the jaw, shoulder, and/or left arm as in the “classic” type of chest pain caused by a low blood supply to the heart.

  • S (Severity):  How severe is the pain? Some doctors will ask you to rate the pain on a scale from 1 to 10, with 10 being the worst pain in the world you can possibly imagine. Chelsea's pain is moderate, about 6 out of 10.

  • T (Timing):  When does it occur and for how long? For Chelsea, it happens every night at bedtime for the past 2 weeks and lasts an hour.

I also want to know:

  • Does anything make the pain better or worse?  Chelsea does notice that it’s sometimes worse when she's lying down, since it seems to be triggered by sleep.

  • Does she have any associated symptoms? Chelsea says she feels a bit of nausea, but other than that there is no shortness of breath, no breaking out into a sweat, and no heart palpitations.

The Physical Exam

It’s important to evaluate chest pain in person – not only because of the numerous questions doctors need answers to before determining possible causes, but also because it’s really important to examine the heart, lungs, and abdomen to get more information. 

Chelsea’s heart sounds normal, as do her lungs. But she does have some very mild tenderness when I press on her upper abdomen/lower chest regions.

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