Chest Pain

Differential Diagnosis

Common Diagnoses

  • Angina/MI
  • GORD in adults
  • Anxiety (Da Costa’s Syndrome)
  • Pulled Muscle
  • Tietze’s Syndrome (Costochondritis)

Occasional Diagnoses

  • Pleurisy (e.g. From Pneumonia or Pulmonary Embolus)
  • Peptic Ulcer
  • Biliary Colic
  • Shingles
  • Mastitis
  • Bornholm Disease

Rare Diagnoses

  • Pulmonary Infarct
  • Hypertrophic Obstructive Cardiomyopathy
  • Pericarditis
  • Fractured Ribs
  • Myocarditis
  • Pneumothorax
  • Dissecting Aortic Aneurysm

Ready Reckoner

Key distinguishing features of the most common diagnoses

AnginaGORDAnxietyPulled MuscleTietze’s Syndrome
Worse on ExertionYesPossiblePossiblePossiblePossible
Worse Lying DownNoYesPossibleNoNo
Eased by RestYesPossiblePossibleYesPossible
Chest TendernessNoNoPossibleYesYes
Swelling at Tender PointNoNoNoNoYes

Possible Investigations

Likely:ECG.

Possible:FBC, CXR, pulse oximetry, secondary care cardiac investigations, OGD, ultrasound of abdomen.

Small Print:Helicobacter tests, hospital-based investigations for pulmonary embolus.

  • ECG: May show evidence of cardiac ischaemia, pericarditis or pulmonary embolism.
  • FBC: WCC raised in pleurisy and may be raised in Tietze’s syndrome.
  • CXR: May reveal chest infection, rib fracture, heart disease, cardiomyopathy or pneumothorax.
  • Pulse oximetry: Hypoxia a sign of significant cardiac or respiratory problem in the acute setting.
  • Secondary care cardiac investigations: To clarify whether a cardiac cause.
  • Ultrasound of abdomen: To check for gallstones.
  • OGD: To confirm peptic ulcer or oesophagitis.
  • Helicobacter tests useful in the presence of duodenal ulcer.
  • Hospital-based investigations for pulmonary embolus: If this diagnosis is suspected.

Top Tips

  • The history is all-important and will usually provide the diagnosis. Except in an obvious emergency, take your time getting the facts straight.
  • If you feel worried enough to obtain an urgent ECG then you ought to consider whether the patient really requires an urgent medical opinion or admission.
  • Watching the patient’s hand as the symptoms are being described can provide very helpful clues. A clenched fist on the chest is worrying; a single pointing finger much less so.
  • Musculoskeletal pain and pleurisy both cause pain on deep inspiration – but the former usually also displays muscle or rib tenderness.
  • Tietze’s syndrome is distinguished from costochondritis by the presence of a palpable swelling, caused by oedema, at the site of maximal tenderness. However, management is largely the same.
  • Always encourage the patient to contact you if the problem persists or deteriorates.
  • If in doubt, play safe: Give aspirin (if not allergic) and admit.
  • If the diagnosis remains unclear, examine the abdomen, especially for significant epigastric tenderness.

Red Flags

  • Don’t delay if the symptoms clearly suggest an infarct; admit the patient (via the telephone if necessary).
  • A normal ECG does not exclude an infarct. Treat the patient, not the test.
  • Symptoms of genuine and significant pathology may be clouded by various ensuing anxiety symptoms. Take time to tease them out.
  • Performing unnecessary tests when the diagnosis is clearly anxiety is likely to exacerbate the situation.
  • Be especially careful dealing with acute chest pain in patients with asthma or COPD, especially if they are suddenly more short of breath than usual, too – remember, they are more prone to developing a pneumothorax.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.