Monday, August 29, 2011
Imagine visiting with your boss at work when you notice that he looks a little short of breath. He mentions that the left side of his chest hurts a bit and he just can’t get comfortable. So went the tale of Toronto Blue Jays manager John Farrell. His assistant took him to the team doctor and soon he was on the way to the ER to get checked out. Fortunately, the pain was due to an infection of the lung or pneumonia and recovery is expected with some antibiotics by mouth and some time to recuperate.
The symptom of chest pain causes people to respond in different ways. Some people ignore the pain, hope that it goes away and pretend that something bad might not be happening. Others might be quick to access medical care for fear the worst is happening. But while the patient fear only a heart attack, the doctor starts considering all the things in the chest that could be fatal. Heart attack or myocardial infarction is only one potential killer but other can include ruptured or dissecting aortic aneurysm, pneumothorax (collapsed lung), pulmonary embolus (blood clot in the lung) and Boerhaaves Syndrome (ruptured esophagus). And to make things more complicated, disasters in the abdomen like perforated bowel or pancreatitis can cause chest pain.
The diagnosis of chest pain and the direction of care depend upon taking an accurate history and trying to understand what the pain feels like. Pleuritic pain or pain that hurts to take a deep breath usually comes from the lung while angina or pain from the heart is classically described as a heavy feeling or tightness. Heartburn type pain might be due to esophageal irritation and reflux. Where the pain starts and where it radiates may give a clue to its origin. Pain that radiates to the shoulder blade may be due to irritation of the diaphragm, the muscle that separates the chest from the abdomen, while burning pain from the esophagus often begins in the upper abdomen and radiates to the back of the throat. Angina may radiate to the jaw or teeth, the shoulder and arm or to the back. Aorta pain radiates to the back. Pain from the chest wall tends to radiate circumferentially around the chest wall. And one can’t forget the associated symptoms of shortness of breath, sweating and nausea and vomiting which can crossover many organs.
Getting the right diagnosis gestalt requires knowing about the patient’s past history and considering the risk factors for different diseases. High blood pressure, high cholesterol, diabetes and smoking increase the risk of heart attack and aortic dissection. Recent immobility like airline travel, a long car ride or operation increases the risk of pulmonary embolus. But smoking increases the risk of pneumonia and bronchitis as well as esophagitis and reflux.
Diabetes and women are the wild cards in the equation. Illnesses can present atypically and not follow normal pain patterns. In fact, most patients don’t read the textbook when it comes to chest pain. It is up to the doctor to have a high index of suspicion that routine presentations of chest pain are the exception not the rule. This is where experience and the art of medicine coexist with science. It is painful and expensive to run tests to make certain that every bad thing that could happen has not. Making appositive diagnosis has to be balanced but being comfortable that disaster isn’t looming around the corner.
The diagnosis of Mr. Farrell’s pneumonia took a brief time in the ER. Some patients get frustrated that they wasted time and money because their chest pain symptoms were not caused by a killer disease. Doctors, nurses and hospitals, have made an aggressive advertising effort to get people to seek emergent care when chest pain strikes. It gives an opportunity to intervene and it’s just good news if the cause is something that can be treated at home. And based on his team’s performance, Mr. Farrell can use all the good news he can get.