Differentials
Pneumonia with pleurisy
SIGNS / SYMPTOMS
Pleurisy results in localised chest pain that is worsened by deep breathing.[112]
In the setting of pneumonia, patients will commonly complain of dyspnoea, fevers, cough, and sputum production.
On examination, bronchial breath sounds and dullness to percussion may be appreciated in focal lung region.
INVESTIGATIONS
A pulmonary infiltrate with or without an effusion is typically seen on chest radiograph.
Oesophagitis
SIGNS / SYMPTOMS
Dysphagia and odynophagia are the predominant complaints of oesophagitis.
Infectious oesophagitis typically occurs in immunocompromised patients.[113]
Medications should be reviewed for common offenders of pill-induced oesophagitis.[114]
History of radiotherapy may raise suspicion for radiation oesophagitis.
INVESTIGATIONS
The results of barium swallow and endoscopy are dependent on the cause of oesophagitis.
Candida albicans will appear as a shaggy mucosa on barium swallow and numerous small white-yellow plaques on endoscopy.
Herpes simplex virus appears as small ulcers on barium swallow and oesophagogastroduodenoscopy, whereas large, deep, and linear ulcers suggest cytomegalovirus.[113]
In suspected pill oesophagitis, endoscopy may be indicated to exclude infectious causes.[114]
Barium swallow and endoscopy can demonstrate the severity of mucosal damage with radiation oesophagitis.
Oesophageal spasm
SIGNS / SYMPTOMS
Patients may complain of intermittent chest pain and dysphagia in the setting of oesophageal spasm. Glyceryl trinitrate can improve oesophageal spasm by inducing smooth muscle relaxation.[115] This can make oesophageal spasm difficult to differentiate from angina.
INVESTIGATIONS
Barium swallow may show prominent non-propulsive contractions leading to a corkscrew appearance.
Oesophageal manometry may demonstrate repetitive and aperistaltic contractions.[115]
GORD
SIGNS / SYMPTOMS
Oesophageal reflux typically presents as an epigastric or retrosternal burning pain, with radiation towards the throat. Patients may report resolution of the pain with a trial of antacids.[116]
INVESTIGATIONS
Typically managed empirically with acid-suppressive therapy. Oesophageal pH monitoring can be performed to demonstrate episodes in which the oesophageal pH drops to below 4.[116]
Biliary colic
SIGNS / SYMPTOMS
The pain of biliary colic is localised to the right upper quadrant, occurring 15 to 30 minutes after a meal and persisting for 3 to 4 hours. It is often associated with nausea, vomiting, and bloating.[117][118][119]
INVESTIGATIONS
Ultrasound or hepatobiliary iminodiacetic acid scan will reveal gallstones.[117]
Peptic ulcer disease
Costochondritis
SIGNS / SYMPTOMS
The pain of costochondritis is typically localised to one or more of the costochondral or costosternal junctions, with reproduction of the pain on palpation.
INVESTIGATIONS
Diagnosed solely on reproduction of the pain with palpation of the tender areas.
Fibromyalgia
SIGNS / SYMPTOMS
Tender points of fibromyalgia can be located to near the sternum along the second intercostal space. Additionally, patients may complain of fatigue and chest heaviness. Patients with fibromyalgia will typically have multiple additional tender points localised to the neck, buttocks, shoulders, arms, and upper back.[121]
INVESTIGATIONS
Diagnosis is on clinical grounds by identifying point tenderness areas (typically, patients will have at least 11 of the 18 classic tender points) with no accompanying tissue swelling or inflammation, and by excluding other medical conditions as a cause.[121]
Rib fracture
SIGNS / SYMPTOMS
Rib fractures are often preceded by a history of traumatic injury to the area and pain is often localised to the area of fracture.
INVESTIGATIONS
Chest radiograph may show rib fractures. Pain with palpation of the tender area also suggests the diagnosis.
Sternoclavicular arthritis
SIGNS / SYMPTOMS
The pain of sternoclavicular arthritis is usually maximal immediately over the sternoclavicular joint. A history of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis should raise suspicion for this diagnosis.[122]
INVESTIGATIONS
Diagnosis is usually on clinical grounds as the joint is poorly visualised by conventional radiography.[122]
Herpes zoster virus infection
SIGNS / SYMPTOMS
The majority of patients with herpes zoster will have a prodromal pain in the dermatome that will become affected. Before the development of vesicles, it can be difficult to differentiate this chest pain from other causes of chest pain.[123]
INVESTIGATIONS
Dermatomal distribution and presence of vesicular skin lesions.[123]
Anxiety disorders and panic attacks
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