Chest pain and cough

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning

Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Cardiac Pericarditis[1][2][3] Acute or subacute May last for hours to days + + + -
Pericardial Tamponade[4][5] Acute or subacute May last for hours to days +/- + + - EKG findings:
Myocarditis[6][7][8] Acute or subacute Variable +/- + + -
Heart Failure[9][10][11] Subacute or chronic Variable
  • Dull
  • Left sided chest pain
 + - + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pulmonary Pulmonary Embolism[12][13] Acute May last minutes to hours + +/- + -  Hormone replacement therapy

Cancer Oral contraceptive pills Stroke  Pregnancy Postpartum  Prior history of VTE Thrombophilia 

Pneumonia[14][15][16] Acute or chronic Variable
  • Dull
  • Localized to side of lesion
 + + + +/-
  • Long hospital stay
  • Ill contact exposure
  • Aspiration
Tracheitis/ Bronchitis[17][18][19][20] Acute Variable + + + -
  • Peaked P-wave
Pleuritis Acute or subacute or chronic May last minutes to hours + + + -
  • EKG done to rule out other causes in differential diagnoses
Pulmonary Hypertension[21][22][23] Acute or subacute or chronic Variable + - + -
Pleural Effusion[24][25][26] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Asthma & COPD[27][28][29][30] Acute or subacute or chronic Variable
  • Tightness
 + +/- + +/-
Pulmonary Malignancy[31][32][33][34] Chronic Variable
  • Dull aching
 + +/- + +
  • EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
Sarcoidosis[35][36][37][38] Chronic Days to week
  • Chest fullness
 + - + +
  • Diminished respiratory sounds
Acute chest syndrome (Sickle cell anemia)[39][40][41] Acute May last minutes to hours
  • Chest tightness
 + +/- + -
  • EKG typically not indicated
 ---
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal GERD, Peptic Ulcer[42][43][44] Acute +/- - - +/-
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
Diffuse Esophageal Spasm[45][46][47][48] Acute
  • Minutes to hours
  • 5 to 60 minutes
 + - +/- +/- --- ---
  • Barium swallow: Multiple areas of spasm throughout the length of the esophagus
  • Impedance testing: Higher amplitudes and better transit of swallowed boluses
  • No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES 
  • Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)
Esophagitis[49][50][51] Acute Variable + + - +/-
  • No auscultatory finding
Eosinophilic Esophagitis[52][53][54][55][56][57] Chronic Variable + - - -
  • No auscultatory finding in the this disease
  • Typically no finding on EKG
Mediastinitis[58][59][60][61] Acute, Chronic Variable
  • Retrosternal irritation
 +/- + + -
  • Nonspecific
  • Infection
  • Esophageal perforation
  • Post operative complication
  • Positive organisms in sternal culture
  • Leukocytosis
  • Positive blood cultures
  • Diffuse ST elevation
  • CT: Localize the infection and extent of spread
  • MRI: Assesses vascular involvement and complications
 CT scan
Sliding Hiatal Hernia[62][63][64] Acute Variable + - + -
  • Trauma
  • Iatrogenic
  • Congenital malformation
  • Bowel sounds may be heard in the chest
  • Non specific
  • T wave inversion in anterior lead.
  • Barium swallow: At least three rugal folds traversing the diaphragm 
  • Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
  • High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough
  • Upper endoscopy
  • High resolution manometry (for smaller hernias)
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab workup EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Rheumatic Relapsing polychondritis[65] Chronic Years Intermittent pain in: + + + +
  • Autoimmune diseases
  • Negative rheumatoid factor
  • Anti-type II collagen antibodies
  • Antineutrophil cytoplasmic antibodies
  • ECG is done to rule out the cardiovascular complications of this disease
  • Non specific
  • Related to specific organ involvent
  • No gold standard test for this disease
Psychiatric Panic attack/ Disorder[66][67][68] Acute or subacute or chronic Variable Variable + - + -
  • Psychiatric disorders
  • Anxious
  • Tachypneic
  • Thyroid function tests
  • Complete blood count
  • Chemistry panel
  • Sinus Tachycardia
  • No any specific radiographic test is done
 ---
  • Others
 Substance abuse

(Cocaine)[69][70][71]

Acute (hours) Minutes to hours Pressure like pain in the center of chest + + + +
  • Psychiatric disorders
    • QT prolongation
    • Sinus Tachycardia
    • Arrhythmias
    • Cardiac conduction abnormalities
 ---
  • Gold standard test depends on the type of substance is abuse

References

  1. ↑ Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R (March 2004). "Day-hospital treatment of acute pericarditis: a management program for outpatient therapy". J. Am. Coll. Cardiol. 43 (6): 1042–6. doi:10.1016/j.jacc.2003.09.055. PMID 15028364.
  2. ↑ Troughton RW, Asher CR, Klein AL (February 2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
  3. ↑ Spodick DH (March 2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. PMID 12622586.
  4. ↑ Ewart W (March 1896). "Practical Aids in the Diagnosis of Pericardial Effusion, in Connection with the Question as to Surgical Treatment". Br Med J. 1 (1838): 717–21. PMC 2406464. PMID 20756103.
  5. ↑ Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F, Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J (November 2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)". Eur. Heart J. 36 (42): 2921–64. doi:10.1093/eurheartj/ehv318. PMID 26320112.
  6. ↑ Dec GW, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA (April 1985). "Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome". N. Engl. J. Med. 312 (14): 885–90. doi:10.1056/NEJM198504043121404. PMID 3974674.
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  10. ↑ Horwich TB, Kalantar-Zadeh K, MacLellan RW, Fonarow GC (May 2008). "Albumin levels predict survival in patients with systolic heart failure". Am. Heart J. 155 (5): 883–9. doi:10.1016/j.ahj.2007.11.043. PMID 18440336.
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