Anyone can think like a doctor if they know what to think about.
Chest pain can be a serious symptom depending on its cause. But 99 out of 100 times, it is not very dangerous. Knowing how to evaluate chest pain is usually left to the doctor. But if you know how a doctor thinks and can analyze your own chest pain in a similar fashion, you may be able to determine what to do next.
The list of dangerous diseases for people that present with chest pain is rather small but includes problems that can lead to significant disability and even death. These include heart attack, blood clot, dropped lung, pneumonia, tearing of the aorta blood vessel, or esophagus rupture. This is why chest pain causes a large amount of anxiety in our society and brings many people into the emergency department for an evaluation. This is the job of the emergency physician — to rule out dangerous diseases.
There are certain tests that can only be done in the emergency department so unfortunately, you cannot trade the advice in this article for the full evaluation and workup that can be done by a physician. But I also think it’s important for the general public to understand what might and might not be dangerous. And there are ways that physicians think about chest pain, an algorithm so to say, that can be a benefit to the non-medically trained.
We do this by a concept known as pattern recognition. By experiencing patient issues hundreds and thousands of times, we are tuned into specific patterns within the patient’s story and attributes that lead us to think of possible diagnoses. Yes, this takes time to learn and experience to master. But it’s easy to let you in on some of the secrets of the trade. Here goes…
The first thing I think about when a patient presents with chest pain is their age. If the patient is under 30 years old, then it is very unlikely that they are having a heart attack. In fact, even though it has occurred, in my 13-year career, I have never seen anyone have a heart attack under 30 years old. So as soon as someone comes in under 30 with chest pain, I immediately start thinking of other potential causes.
First, and for the majority, the most common problem is likely to be a musculoskeletal strain of the chest or perhaps costochondritis, which is an inflammation where the ribs meet the sternum. Though workups for other causes may be appropriate, most chest pain in the younger age group is quite benign.
If the chest pain is more dangerous, potential causes in a younger age group would be a blood clot depending on genetics, recent surgeries, pregnancy, or prolonged immobilization — for instance, a long plane ride overseas. Another cause could be a pneumothorax which is a dropped lung. This usually occurs in young tall lanky males. The final cause that could be concerning is an aortic dissection which is a tearing of one of the blood vessels in the chest. All three of these are rather rare might be considered in the right setting.
Finally, depending on the symptoms, pneumonia can cause chest pain, asthma can cause chest pain, and there are other conditions such as acid reflux that can cause this pain. The older you are, the more chance of a serious disease. Generally, chest pain under 40 tends to be harmless.
In medicine, we like to say that the patient story gets us around 80 to 90% of the way to a diagnosis. So if a patient comes in and says they are having crushing chest pain that started while they were mowing the lawn, and their age is correct, they certainly could be having a heart attack.
The same can be said for a patient who comes in and says that they recently had knee surgery and now they’re having chest pain with associated shortness of breath. The first thing to pop into my mind is a pulmonary embolism or blood clot in the lung.
On the flip side, if someone was working out in the gym doing bench presses and then developed some chest pain that’s worse with movement and sore to the touch, a muscle strain is a good possibility.
Pay close attention to the story — how the chest pain started — and it will give you some good insight into what it might be.
Concomitant problems and risk factors
If you are a young and otherwise healthy person and you have never had any major medical problems — and of course you see your primary care physician for a yearly physical — then it is unlikely you’re going to suddenly develop a dangerous disease. However, depending on your age, anything can happen at any time. Once you get above around 50 years old, all bets are off.
If you do have some problems already, including high blood pressure, high cholesterol, diabetes, obesity, smoking history, or any number of genetic abnormalities, you may be at higher risk for some of the major diseases that can be caused by chest pain. These would make me think twice and order more testing to make sure that nothing serious is going on, even though there is still a high likelihood that everything will be fine.
I am usually reassured by patients who have had recent tests that have been negative. For instance, if a patient has had a catheterization in the past year that was normal, it is very unlikely that they are going to have a heart attack. On the other hand, stress tests are only about 80 to 90% sensitive, so they can sometimes miss serious heart disease. Just because someone had a stress test the day prior doesn’t mean that their chest pain is not a heart attack.
On the same token, if someone has had a negative CAT scan of their chest in the past month, it is going to be very unlikely that they have a blood clot or aortic dissection, so I am usually reassured and do not always feel the need to repeat these tests.
If you have never had a test before, have a good story, are of the right age, and have some risk factors, then it’s worth some testing to rule out more serious diseases.
Putting aside the age, history, risk factors, and recent tests, family history can be a huge determinant of chest pain.
If you have a first degree relative with heart disease who had a heart attack at a young age, then you are at risk and need an evaluation if you are having chest pain.
The same goes for blood clots and aortic dissection. Family history is extremely important to me and for other doctors and drives us to order more tests when someone has a confirmed relative with serious disease.
This may be more appropriately linked to history, but I believe is important as its own category. If someone has chest pain associated with shortness of breath, then certain problems come to mind. This may be pneumonia, or asthma, or a heart attack.
One question I might ask is whether the patient is short of breath or whether they have pain with deep inspiration. This changes the thought process slightly since pain with deep inspiration could be more consistent with pneumonia or blood clots instead of other causes.
Other symptoms might include leg pain, nausea, sweating, or passing out. Pattern recognition allows us to look at these symptoms together to form a hypothesis in our heads. We then order tests to confirm or refute the hypothesis.
What can you do?
While I don’t encourage you to use this article so that you don’t have to go to the doctor, there are a number of ways this article can help you.
- If you’re young, it can reassure you and take away some of your pent up anxiety about your condition.
- You can analyze your own chest pain to provide better information to your doctor when you are evaluated.
- You can be a better-informed patient, understanding what doctors are looking for and why they order the tests they order.
Today’s world requires savvy patients that can make decisions with their doctors rather than expecting the doctor to make all of the decisions. Having information about how doctors think can help you be an informed individual and improve your own health.