胸痛是临床常见症状，主要是胸部疾病所致，多数由呼吸系统和心血管系统疾病引起，也可以是胸壁疾病或来源于腹部脏器病变；包括钝痛、隐痛、持续性痛，刺痛、灼痛或压迫痛。胸痛的原因有很多，且胸痛的部位和严重程度，并不一定和病变的部位和严重程度相一致。重点采集疼痛的发作时间、性质、部位、频率、持续时间、诱发因素及伴随症状等。

Chest pain is an important and common presenting symptom in our daily clinical visits.Many patients worry that their chest pain is due to a serious heart problem,such as a heart attack.However, the differential diagnosis for chest pain is wide, many of which are non-cardiac in origin(e.g., musculoskeletal pain, gastro-esophageal reflux disease, esophageal spasm, chest infection,pulmonary embolism).Cardiac causes of chest pain include myocardial infarction, angina and pericarditis.

A careful history of the symptom of chest pain helps to determine or narrow down the causes(differential diagnosis)of the patient’s chest pain and choice of appropriate investigations.In the history, one should determine:

(1)The location of the pain.E.g., central, across the chest, to one side, at the front or back, located diffusely or in a small spot?

(2)The nature of the pain.E.g., dull, pressing,squeezing, sharp, stabbing, burning.

(3)Whether the pain radiates, and if so, where.E.g.,to the neck, jaw, throat, or arm.

(4)Duration of the pain each time it occurs.E.g,, a few seconds, minutes, hours or days.

(5)Frequency of the pain.E.g., a few times a day,once a week, present all the time.

(6)Any exacerbating and relieving factors.E.g., is the pain brought on or made worse by physical exertion/exercise, food, cold weather, emotional upset, deep breathing, coughing, or touch? Is the pain relieved by resting, change in posture/position, or medication(such as GTN spray, pain killers, antacids)?

(7)Any associated symptoms.E.g., cough(dry or productive, and nature of the product in the latter),breathlessness, orthopnoea, para nocturnal dyspnea,autonomic symptoms, water-brash, symptoms suggestive of infection.

D: How may I help you?

P: I have chest pain and I get very short of my breath nowadays, so I thought it best to come in and see you.D: How long have you had this problem?

P: Two weeks now, and it seems be getting worse.

D: What does your chest pain feel like?

P: It feels like a dull ache across the center of my chest.

D: Does the pain move to any other area?

P: Yes, it moves up my neck, left shoulder and down the left arm.

D: Is the pain there all the time?

P: Well, the pain comes and goes often.

D: Does anything make it worse, for example when you exert yourself?

P: Yes, it gets worse when I walk too fast or climb the stairs.

D: Do you feel sick or sweaty when you get the chest pain?

P: Well, I don’t feel sick but I often break out into a sweat.

D: Did you have chills and fever at the same time?

P: Yes.For a couple of days I felt as though I have a fever.

D: Do you have a cough?

P: No.

D: Have you received any treatment before coming to this hospital?

P: No, I haven’t.

D: Do you smoke？

P: Yes.I have smoked for 20 years.

D: Do heart problems run in your family?

P: Let me see.My father has high blood pressure.And my mother died of a heart attack.

D: May I examine you, please?

P: Okay.

D: Please take off your clothes and socks, leaving your underwear on, then lie on the bed.There is a blanket here which you may use to cover yourself.Afterwards,we will do an ECG, chest X-ray and blood test to help find out what is causing your chest pain.

P: What’s wrong with me?

D: It is likely that you have angina, which is chest pain due to the lack of blood supply in the heart.Often this is due to narrowing or blockage in one or more blood vessels in the heart.

P: Is it serious?

D: It is a coronary heart disease, a condition that can cause heart attack.However, with treatment, your angina can get better or disappear, your chance of a heart attack can be reduced, and your future made better.

P: What should I do now?

D: Because you are having chest pain at rest and not just on exertion, it is best that you should be admitted to the hospital for treatment with medications and undergo further tests.It is likely that you will need a coronary angiogram to confirm the diagnosis and help decide on the best treatment for you.You should give up smoking, avoid too much fatty food and eat a balanced diet.Do you have any question?

P: No, thank you very much.

D: Hello, how may I help you?

P: I have chest pain and am getting very breathless, so I thought it is better to come and see you.

D: When did the symptoms begin?

P: Three hours ago.

D: Do you still have the pain?

P: Yes.

D: Is the pain there all the time or does it come and go?

P: It’s there all the time.

D: Where on your chest is the pain?

P: In the middle.

D: Does the pain move anywhere else?

P: No.

D: Is the pain and breathing worse when you get up to walk?

P: It’s worse when I try to do something.

D: Can you lie flat in bed?

P: Yes, I can.

D: Do you feel better when you lie in bed?

P: It seems a little better.

D: Do you have a cough?

P: Yes.

D: Do you bring anything up when you cough?

P: Yes, I coughed up some blood.

D: Have you received any treatment before coming here?

P: I had ultrasound scan of my legs and heart.

D: How about it？

P: Here are the reports.

D: Let me have a look.There is a blood clot in your left leg.I’d like to listen to your chest.Would you mind taking off your coat? Breath in and out I think we should do a blood test, ECG and chest X-ray to help assess your condition.

D: It is likely that you have pulmonary embolism, which means blood clot in the lung.The blood clot mostly likely originated from the blood clot in your left leg.

P: Oh, that’s so terrible! What should I do now?

D: Pulmonary embolism is a potentially life-threatening condition, but it often responds well to early treatment with medication.I recommend that you be admitted to hospital so that your treatment can start at once.You should stay in the bed.You’ll be given drugs to ease the pain, and oxygen to help you breath better.You will also be given medication to thin your blood, to help dissolve the blood clot in your leg and lungs.I’ll also arrange a CT scan of your chest to confirm the diagnosis.Is there anything that you wish to ask?

P: No.I got it.Thank you very much.