EVALUATION of CHEST SYMPTOMS
CHEST PAIN and TROUBLE BREATHING
V. 1.2 3/21/10 under development
for the non-professional, without medical training
where there is no access to a physician.
Probably nothing creates so much anxiety in people as acute chest pain, at least if the thought of a heart attack comes to mind. Much can be done to determine, without technology such as lab, xray and EKG, whether a specific pain is something serious or not. Do note however that there are things other than heart attack that can kill. So, how can you sort this out?
Duration. How long does it last. Fleeting (seconds), a few minutes, more than half an hour, several hours, ongoing over several hours, days.
Where is it. Well localized or more diffuse, central or on one side, can you point at it with one finger.
What does it feel like. Sharp, dull, pressure, a weight on the chest, squeezing, burning.
Are there other symptoms. Fever, cough, nausea or vomiting, sweating, dizziness, palpitations, (i.e. a fluttering in the chest or awareness of the heart beating, especially if irregular or unusually fast or slow), eye symptoms, abdominal pain, back pain.
When does it occur and what makes it better or worse. With movement, breathing, cough, exertion of the rest of the body, (i.e. walking, running), with eating or swallowing.
Fleeting: If the pain is fleeting, only a few seconds and then gone and you otherwise feel fine with no ongoing symptoms, don't worry about it, lots of us get fleeting pains. They may be spasms of the muscles between the ribs or slight tweaks of rib joints, especially if triggered by movement, cough or sneeze. These pains are generally sharp and well localized.
Brief but repetitive:
1) Does it hurt to move or breath?
A pain that occurs with movement but not breathing is likely in the chest wall, i.e. ribs, muscles etc. Generally there is also some precipitation or exacerbation with breathing. Again sharp and may be localized. Is it tender? If it clearly hurts to breath or cough it's called a pleuritic pain. If it's not also tender start to consider lung problems, (pneumonia, bronchitis, pneumothorax, pulmonary embolus).
2) Very transient: just a second or a few seconds: Could be a palpitation (abnormal sense of heart beating) but is often a transient sharp local pain of a chest wall spasm. We all get those occasionally for no apparent reason, and they have little or no significance.
A few minutes:
Whether a single episode or repetitive the same things need to be considered. Associated with swallowing or eating? Is there regurgitation, burning, bitter taste? Either way see esophageal problems. Brought on by exertion? See heart. Began while not doing anything, i.e. at rest, pay attention to the type and location and see heart, pneumothorax, dissecting aneurysm, pulmonary embolus though the latter two generally last longer.
More than half an hour:
These may be minor or life threatening. If heavy, crushing, squeezing and either central or generalized and especially if it radiates, (i.e. also goes into), the left or both arms or neck or if other symptoms such as nausea, cold sweat, see heart. If it hit you in the back, see dissecting aneurysm. Otherwise esophagus or lung. Likely minor if tender (see) or mild pain and no other symptoms.
More than 12 hours (continuous) or days:
If it's a heart attack, you should have got to treatment sooner. Otherwise think chest wall pain or possibly lung. Look at the whole situation. The longer the pain lasts without dramatic changes the less likely it is to be an emergency and usually its something not serious such as chest wall pain, but once in a while it's disastrous, e.g. cancer.
You can point at it with one finger. It's either chest wall pain or pleurisy.
Spread over a few inches:
Could be the same as the well localized but: If central consider heart or esophagus unless coughing suggests lung. If on one side think lung. Left side is occasionally heart.
Throughout the whole chest suggests heart or esophagus.
Goes through to the back:
Hopefully esophageal or gall bladder but can be heart and must always consider dissecting aneurysm.
Sharp chest pains are generally not heart unless pericarditis (see) but some may call any severe pain "sharp" so see heart pains. Make sure we're talking sharp as a quality, not sharp as severity.
More likely an internal pain, heart, lung, esophagus
Pressure, Weight on chest, Squeezing, Gripping:
All these suggest heart but can be esophagus.
Think esophagus or irritation from coughing, i.e. bronchitis/pneumonia.
When and How. Timing and progression
Key to sorting out the serious chest pains is the circumstances that an acute severe pain occurs. Don't panic yet though. How does the patient look? Onset at rest or instantaneously doing nothing in particular: If short of breath and sharp, localized, pleuritic pain; think pulmonary embolus or pneumothorax. Same with less trouble breathing, especially with back pain, consider dissecting aneurysm. Dull pain with other symptoms, consider heart. Is it brought on by exertion? This is the key tip-off to heart pains. Triggered by swallowing or recent meal? Think esophagus, though heart is possible.
Other associated symptoms:
Short of breath (i.e. a feeling of air hunger, not the same as hurting to breathe): Heart or lung
Nausea: Think heart first, then esophagus and stomach.
Drenching cold sweat: Think heart strongly.
Belching and regurgitating food, bitter taste, worse lying down: Think esophagus
Lightheaded and/or palpitations: Think heart but could be something minor like anxiety.
Cough or fever: Lung
Anxiety: The main question is: Anxiety causing chest pain, anxiety about the chest pain, or anxiety as part of the symptom complex of a severe cause of chest pain? Heart attacks are often accompanied by a sense of overwhelming doom.
One eye is red, with a cloudy cornea, swollen: Check out acute glaucoma. It's rare but catastrophic.
Rate of breathing. (12-16 normal, over 25 very significant)
Depth of breathing: Adequate chest wall movement? Symmetrical?
Laboring: Needing to sit up? Neck muscles standing out? Skin pulling in between the ribs or over the collar bones.
Coughing. Is sputum (phlegm) being brought up? Is it colored? Bloody?
Alertness? Can the patient talk in full sentenses? Or only a couple words. Or fading out of consciousness?
Palpation: What it feels like.
If the tenderness reproduces the pain it's a chest wall pain (trauma, rib fractures, strain, costochondritis) and probably not serious unless also truly short of breath, (not just that it hurts to breath.)
Vibration: Is it symmetrical?
Feel with the palm of your hand while the patient speaks, e.g. says "99"
Percussion: (Tapping on it.)
Should be resonant, (hollow sounding), except over the heart. Hyperresonant, (drum like) on one side suggests pneumothorax, (popped and collapsed lung.) Naturally dull over the heart but if dull elsewhere there’s too much fluid, either outside the lung, (blood or ‘water’), or within the lung, (pneumonia).
Use a stethoscope if it’s available, otherwise put your ear to the chest. (The stethoscope was invented, depending on the story you like, either to protect women’s modesty, or to get around large breasts.)
Normal, (vesicular). Get used to them by listening to your family’s or lover’s lungs. Usually they’ll be normal.
Rales: Fine rales sounds like rubbing your hair between your fingers by your ear. They’re fairly common in relatively normal chests, especially in the bases, and especially in the older lungs. If only heard on one side they’re likely to be abnormal. They indicate the tiny air sacs popping open. Coarser, moister rales sound like bubbles popping, almost like pop fizz. It’s fluid bubbling in the tubes. Either are only during inspiration, (breathing in).
Rhonchi: Coarser even raspy sounds that may be during inspiration or expiration.
Wheezes: Musical whistling sounds caused by turbulence because of narrowed small airways. They usually indicate bronchospasm due to asthma or emphysema but occasionally are due to swollen airways due to inflammation or heart failure. The higher pitch the wheezes, the worse the problem. Wheezes may or may not be audible to the bystander. They’re always audible with stethoscope, unless the obstruction is so bad that insufficient air is being moved to cause the noise. Then you’ll probably just be aware that the breath sounds are very diminished, the length of expiration is prolonged, (over 3 seconds), and the patient is in significant distress. Mild bronchospasm may only cause wheezing with forced expiration, i.e. by trying to exhale as rapidly as possible after taking a deep breath.
Stridor: A coarser, harsher whistling sound audible to the bystander and loudest at the base of the neck. This indicates blockage at the level of the larynx, vocal cords or trachea in the neck. This is always dangerous, regardless of the cause.
The heart exam:
I wouldn’t expect anything more than being able to notice the rhythm. Is it regular? How fast? (Normal is between 60 and 100.) Slower is only a problem if there’s associated problems such as lightheadedness, passing out, or trouble breathing. Fast and regular usually isn’t much of a problem, (unless having a heart attack), unless it’s over 150. If it’s irregular it may or may not be a problem. More important is what other symptoms there are.
Trauma, rib fractures, strain, costochondritis
Localized tenderness that reproduces the pain. The first 3 would likely be suggested by the history. Sometime just coughing or sneezing is enough injury. An easy screening test for rib fractures is pain elicited by squeezing the chest between two hands. Try it both from side to side and front to back. The confirmation of rib fractures is that the area of the fracture will hurt even if you push firmly on that specific rib from some distance away from the fracture. Listening to the lung sometimes reveals a pop or crunch as the broken ends rub each other. You may
also feel this as you check for tenderness.
Costochondritis is an inflamation of a rib joint where it meets the sternum (breast bone). There may be actual redness and swelling. It’s generally caused either by inflamation that sets in a few days after an injury, or it follows a viral infection by a week or two.
Treatment: Any of these problems should be treated by avoiding what hurts, ice bag application, and anti-inflammatories, (e.g. fairly high dose aspirin or ibuprofen taken consistently for several days. I.e. 8-12 aspirin or up to 2400 mg ibuprofen per day.
Complications: If there is true difficulty breathing, (not just pain), after chest trauma, there may be lung damage underneath. Bruised lungs can occur, (pulmonary contusion) that can deteriorate over hours to a few days. Also internal bleeding can occur, (hemothorax), or a lung can be popped and collapse. (pneumothorax).
Bronchitis and pneumonia:
Both of these are infections. The difference being that in pneumonia the body of the lung itself is infected and not just the airways. Pneumonia therefore can cause occasionally severe difficulty breathing. It’s more important to determine the difficulty breathing than it is to be sure whether or not pneumonia is present.
Clues: Certainly fever is the best tipoff. But remember that your temperature normally varies during the day. A fever doesn’t convincingly exist unless the temperature is over 100.5° F. (Ignore statements such as, “But I normally run low.”) Cough is present at some stage, but sometimes pneumonia can develop rapidly enough that cough may not be prominent early. If the cough is dry or producing only clear or white sputum, there is not difficulty breathing, and the signs of pneumonia are absent or minimal, then it’s likely to be viral and antibiotics won’t help. Lots of bodily aches and pains, headache and upper respiratory symptoms such as runny nose and sore throat, and swollen glands all suggest viruses. Colored sputum, e.g. green, yellow, occasionally blood streaked all suggest a bacterial infection and antibiotics are warrented. Erythromycin is generally the first choice though others are good substitutes, e.g. penicillin, amoxicillin, tetracycline or doxycycline, trimethoprim/sulfa (Bactrim or Septra).
Bronchitis: Remember that the problem is in the larger airways, not the lung tissue, so. No shortness of breath or labored breathing. Lungs are likely to sound either normal or have rhonchi. Both lungs will sound the same. Percussion is normal.
Pneumonia: Most of the time shortness of breath isn’t severe, but obviously you need help if it is. If lung findings are on both sides, the pneumonia is likely viral, unless it’s severe. If one sided, assume it’s bacterial. There will be rales in the area of the pneumonia. There may be dullness to percussion, (tapping). The breath sounds may be louder at the pneumonia and vibration may be greater.
Antibiotics if bacterial. Don’t try to totally suppress a cough that is bringing up colored sputum. You’d be fighting your body’s normal process of clearing the infection.
Cough suppression: Remember that this is for comfort primarily, not to get you better faster. Codeine is the best cough suppressant, but you don’t need much, i.e. 10 mg. Half of a single Tylenol #3 will be adequate, or a single Vicodin. Dextromethorphan, (the DM in Robitussin DM is pretty fair.) Benadryl (diphenhydramine) can help. Promethazine, (Phenergan) works. All these suppress the cough center in the brain. An alternative approach is to numb the airways with Tessalon, which has the advantage of not impairing alertness.
A productive cough should preferably be loosened by drinking lots of fluids and guaifenesin, (plain Robitussin).
Obstructive Lung Disease
Asthma, Chronic Bronchitis and Emphysema (COPD):
These are the two main diagnoses that have the basic problem of getting air into, and especially out of the lungs. The primary symptom is feeling short of breath.
ISCHEMIC HEART DISEASE . (part of the heart isn’t getting enough blood)
This is heart pain without damage. Classically it’s a pressure type dull chest pain. Many won’t even call it a pain. Sometimes it’s just a sense of abnormal fatigue. It may also be described as a weight or squeezing. It’s NOT well localized or over the heart. It’s a central discomfort around the breastbone or generalized over the front of the chest. It may radiate to the neck, back, teeth, arms, or abdomen. Think of it as a symmetrical discomfort, though it does show some tendency to go more to the left. If just to the right, it’s almost certainly something else. It’s brought on by exertion and relieved by rest. It lasts from 5-30 minutes. Sometimes it’s triggered by a meal or cold. It could also be due to anything that raises your pulse, such as anxiety, pain, fever, or anything that interferes with breathing. It’s relieved by Nitroglycerin and rest. There may be difficulty breathing. Take an aspirin a day to reduce the risk of heart attack. (This must be old fashioned aspirin. Because it reduces the chance of forming a clot and totally blocking off the blood to part of the heart.) Don’t smoke.
This is the same as plain angina but it’s either, 1) New, 2) Occurring more frequently, with less exertion, (perhaps it rest), 3) More difficult to relieve, or otherwise showing a progressing of worsening. It always indicates a need for medical attention to stabilize it because it indicates a critical shortage of blood and a likely progression to a heart attack.
If medical attention isn’t available, get radio assistance. Perhaps you have medications on board that can stabilize it until medical attention is available. Useful medications are some of those also used for blood pressure control and long acting nitroglycerin preparations. REST. Take an aspirin. Don’t smoke.
Myocardial Infarction. (MI): (The Heart Attack)
This translates as death of part of the heart muscle. The pain is like angina, but generally worse, (“the worst pain of my life”), or overwhelming fatigue. The description is the same. It lasts longer, i.e. over 30 min. It isn’t relieved by rest. There are more associated symptoms, e.g. nausea and vomiting, shortness of breath, cold sweats. There may be palpitations, lightheadedness or even passing out, but this is uncommon. About 25% of the time an MI occurs as the first sign of heart disease.
In any event, you need to get to medical attention as soon as possible. If you can get there within 6 hrs. clot dissolving medicines can be given to reduce the damage to the heart, or even prevent permanent damage. Don’t pass off these symptoms as ‘indigestion’. Take an aspirin while you’re waiting. If you can’t get to the hospital quickly, you’re back into the treatment of before 1985 or so. Go to bed. Hope for no complications. Take an aspirin a day. Take a betablocker medication, (e.g. propranolol (Inderal) or atenolol (Tenormin), to reduce the work of the heart. Start VERY GENTLE activity for a few minutes at a time after a few days. The damaged part of the heart won’t scar for several weeks. Don’t smoke.
Physical Exam of the MI
This is generally normal unless there are complications. You may notice an irregular pulse.
Congestive Heart Failure (CHF): This means the heart can’t keep up with the work demanded of it and the blood starts to back up into the lungs, and perhaps into the rest of the body. The classic symptoms are:
1) Trouble breathing during exertion.
2) Trouble breathing when lying flat.
3) Waking up short of breath.
4) Getting up during the night to urinate, especially if more than once. (When this isn’t due to prostate problems.)
5) Swelling of the legs.
The physical exam of CHF finds rales in the lungs on both sides, and often the legs swollen and bulging of the neck veins even when the partially sitting. It's normal that the neck veins may be visible when supine.
Treatment: Diuretics, (water pills). Most commonly this would be Lasix (furosemide). The dosage varies widely by need, from 20 to 240 mg. per day. Potassium is lost with the urine so potassium replacement is needed, eat a couple bananas a day or apricots, or drink orange juice. Unfortunately too much potassium is dangerous, as is too little potassium. Fluid restriction to less than 1 1/2 qts. a day. Salt avoidance. Some types of blood pressure pills, (NOT betablockers.)
I hope you’ve taken a CPR course. Half of all those that die of a heart attack, die before they get to the hospital. The reality though, is that if a victim isn’t easily resuscitated with less than a couple minutes of CPR, *if advanced life support isn’t available*, then the patient's a goner. The only medicine you might have that would help is epinephrine, (adrenaline), and that needs to be given IV. It might work if injected under the tongue.
This typically happens a week or so later and is generally sudden death.
This is an inflamation of the surface of the heart and the sac around the heart. It sometimes follows a heart attack a week or so later, but it has a number of other causes, such as kidney failure, viruses, cancers, and tropical perisites.
Regardless of cause, the symptoms are the same. Chest pain that feels worse lying down and is relieved by sitting up and leaning forward. The pain may be pulsating in time with your pulse. It may get worse with breathing or swallowing. Listening to the heart, a rubbing sound like creaking leather is occasionally heard.
Pericarditis may interfere with the filling of the heart with blood so that the patient may go into shock. This is called pericardial tamponade and the classic findings of this, (which may not all be present) is a weak pulse that gets weaker when a breath is taken, a silent heart, and bulging neck veins when sitting up.
Treatment of pericarditis:
The basic treatment is anti-inflamatories, especially high dose aspirin. That's 8-12 aspirin tablets daily. You need that much to get the anti-inflamatory effect that doesn't start for a couple days. Prednisone is also used. Pericardial tamponade requires surgery.
LUNG DISEASE (other less common diagnoses)