she had excruciating chest pain 

By  Dr. Mike Hansen

When you don’t know the cause of your chest pain!

A 35-year-old woman develops sudden, excruciating chest pain, which occurred while going for a run, and resolved with rest. She’s never had this chest pain before, and the first thing she wants to know is,

You can usually figure out what’s causing chest pain by asking the right questions, but sometimes further testing is needed. Of course, whatever you see on the internet, including this video, is no substitute for seeking medical attention in real life. With that said, by the end of this video, you’ll know my approach to diagnosing chest pain, especially since MANY clues can give away the diagnosis.

So let’s get at it.
Chest pain can originate from all organs in the chest. (heart, lungs, esophagus, nerves, muscles, bones, and joints)
The 3 most serious lung diseases that cause chest pain include
1) Pulmonary embolism, meaning blood clots in the lungs,
2) Pneumothorax, where a lung deflates like a flat tire, and
3) Pneumonia.

Causes of Chest Pain

And let’s not forget about the gastrointestinal tract. Problems with the esophagus can cause chest pain, including GERD (Gastroesophageal Reflux Disease), aka Acid Reflux. Acid Reflux is the most common Non-Cardiac cause of chest pain.

Then you have the very common musculoskeletal causes of chest pain, like costochondritis. Chest pain often induces anxiety, but the reverse is true anxiety, and emotions are often the causes of chest pain….is it the chicken or the egg?
In order to sort out the cause, we have to answer some key questions and understand the context, Like the age of the patient and past medical history. We need to know specifics about the chest pain. It’s the character, duration, and exact location.

What makes the pain worse?
What makes it better?
For example, is it better or worse when sitting up or lying flat?
How about when you take in deep breaths?
And, of course, what are the associated symptoms?
Like shortness of breath?
Back pain?
All very important. Chest pain that originates from the heart can almost always be boiled down to 1 of 5 things: A heart attack, angina, arrhythmias, aortic stenosis, and pericarditis.

Angina refers to chest pain that occurs when the heart muscle isn’t getting enough blood flow. It’s a feeling often described as chest heaviness, tightness, squeezing, crushing, constricting, or sometimes burning in the center of the chest or a little bit left of the breastbone. The pain sometimes radiates to the shoulder and arms, typically on the left side, and can also radiate to the neck and jaw, and upper abdomen.

Stable angina lasts less than 5 minutes. Unstable angina, which is the worse angina, lasts 5-10 minutes, sometimes longer.

When it comes to a heart attack or myocardial infarction, this is caused by a plaque in the coronary artery that breaks off, travels downstream, and lodges somewhere, causing a sudden blockage of blood flow to a particular area of the heart. It’s overall similar to the chest pain with angina, but usually more intense pain, and more likely to feel short of breath, nauseous, and have profuse sweating. The pain builds up over minutes and lasts at least 30 minutes.
Do women have different symptoms from men?
Not really. Women might be less likely to have chest pain when having a heart attack. And they are slightly more likely to have severe fatigue as a presenting symptom.

Pericarditis inflammation of the sac around the heart. Which can be caused by many things, including viruses, including COVID. Pericarditis causes severe, sharp, stabbing chest pain that is worse when taking deep breaths and coughing. The other unique feature about this chest pain is that it’s worse when lying down and better when leaning forward. The pain doesn’t really away until it gets properly treated.

Doctor Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine

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