History

Onset and characteristics of the pain

Instantaneous onset with pain ‘migrating’ to back, neck or jaw suggests aortic dissection (Chapter 50).

Radiation to the back alone is non-specific and can occur with myocardial, oesophageal and musculoskeletal pain.

Previous similar chest pain brought on by effort and relieved by rest (within 10 min), such as exertional angina?

Pleuritic (worse on inspiration and affected by posture) occurs with pericarditis, pneumonia, pulmonary embolism and chest wall pain.

After oesophageal instrumentation (suspect perforation) or insertion of a central line (suspect pneumothorax)?

After severe vomiting, suspect spontaneous oesophageal rupture.

Associated features

Neurological symptoms, even minor transient blurring of vision, suggest aortic dissection.

Haemoptysis suggests pulmonary embolism.

Purulent sputum.

Past history

Known coronary disease? Other known pathology potentially causing chest pain, e.g. gastroesophageal reflux.

Has there been a previous myocardial infarction with similar pain?

Risk factors

For ischaemic heart disease (cigarette smoking, hypertension, hyperlipidaemia, diabetes, family history of early coronary disease).

For venous thromboembolism (page 355 Table 56.1).

For aortic dissection (hypertension, Marfan syndrome, pregnancy).

Examination

Blood pressure in both arms (>15 mmHg difference in systolic pressure is abnormal), and the presence and symmetry of major pulses (if abnormal, consider aortic dissection).

Jugular venous pressure (if raised, consider pulmonary embolism or pericardial effusion with tamponade).

Murmur (if you hear the early diastolic murmur of aortic regurgitation, aortic dissection must be excluded).

Pericardial or pleural rub.

Signs of pneumothorax, consolidation or pleural effusion.

Localized chest wall or spinal tenderness (significant only if pressure exactly reproduces the spontaneous pain).

Subcutaneous emphysema around the neck (which may occur with oesophageal rupture and pneumothorax).

Are there any gross neurological abnormalities (suggesting dissection or vertebral crush fracture)?