Patient+with+Chest+Pain

ISCHEMIC PAIN Cardiac Origin Decreased oxygen supply Coronary atherosclerosis Significant atherosclerosis Coronary thrombosis Coronary, nonatherosclerotic causes Aortic or coronary dissection Coronary spasm Microvascular spasm Cocaine-induced vasoconstriction Increased oxygen demand Hypertrophic cardiomyopathy Aortic stenosis Dilated cardiomyopathy Increased preload (e.g., aortic or mitral valve regurgitation) Tachycardia Myocardial bridging Congenital abnormality of the coronary circulation Noncardiac Origin Decreased oxygen supply Anemia, sickle cell disease Hypoxemia (e.g., sleep apnea, pulmonary fibrosis, chronic lung disease, pulmonary embolism) Carbon monoxide intoxication Hyperviscosity (e.g., polycythemia, hypergammaglobulinemia) Increased oxygen demand Hyperthyroidism Hyperthermia High inotropic state (e.g., adrenergic stimulation) NONISCHEMIC PAIN Cardiac Origin Pericarditis Aortic dissection Noncardiac Origin Gastrointestinal (e.g., esophageal [esophagitis, spasm, reflux, rupture, ulcer]; biliary [colic, cholecystitis]; gastric [peptic ulcer]; pancreatitis) Psychogenic (e.g., anxiety disorders [hyperventilation, panic]; affective disorders [depression]; somatization; cardiac psychosis) Pulmonary (e.g., pulmonary embolism, pneumothorax, pleuritis, pneumonia, pulmonary hypertension) Neuromuscular (e.g., costochondritis, fibrositis, Tietze's syndrome, rib fracture, herpes zoster, thoracic outlet syndrome, sternoclavicular arthritis)

ICD-9CM # 786.50 CHEST PAIN NOS 786.59 CHEST PRESSURE 786.52 CHEST PAIN, PLEURITIC MUSCULOSKELETAL (COMMON)

Trauma (accidental, abuse). Exercise, overuse injury (strain, bursitis). Costochondritis (Tietze’s syndrome). Herpes zoster (cutaneous). Pleurodynia. Fibrositis. Slipping rib. Sickle cell anemia vaso-occlusive crisis. Osteomyelitis (rare). Primary or metastatic tumor (rare).

PULMONARY (COMMON)

Pneumonia. Pleurisy. Asthma. Chronic cough. Pneumothorax. Infarction (sickle cell anemia). Foreign body. Embolism (rare). Pulmonary hypertension (rare). Tumor (rare).

GASTROINTESTINAL (LESS COMMON)

Esophagitis (gastroesophageal reflux). Esophageal foreign body. Esophageal spasm. Cholecystitis. Subdiaphragmatic abscess. Perihepatitis (Fitz-Hugh-Curtis syndrome). Peptic ulcer disease.

CARDIAC (LESS COMMON)

Pericarditis. Postpericardiotomy syndrome. Endocarditis. Mitral valve prolapse. Aortic or subaortic stenosis. Arrhythmias. Marfan’s syndrome (dissecting aortic aneurysm). Anomalous coronary artery. Kawasaki disease. Cocaine, sympathomimetic ingestion. Angina (familial hypercholesterolemia).

IDIOPATHIC (COMMON)

Anxiety, hyperventilation. Panic disorder.

OTHER (LESS COMMON)

Spinal cord or nerve root compression. Breast-related pathologic condition. Castleman’s disease (lymph node neoplasm).

Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., Copyright © 2005 Saunders, An Imprint of Elsevier Previous Next

Initial Assessment

The evaluation of the patient with acute chest pain actually begins before the physician sees the patient, and its effectiveness depends on the actions of office staff and other nonphysician personnel. Guidelines from the ACC/AHA[9] (see Guidelines section of Chap. 49 ) emphasize that patients with symptoms consistent with acute coronary syndromes should not be evaluated solely over the telephone but should be referred to facilities that allow evaluation by a physician and the recording of a 12-lead electrocardiogram.[19] These guidelines also recommend strong consideration of immediate referral to an emergency department or a specialized chest pain unit for patients with suspected acute coronary syndrome with chest discomfort at rest for more than 20 minutes, hemodynamic instability, or recent syncope or presyncope. Transport as a passenger in a private vehicle is considered an acceptable alternative to an emergency vehicle only if the wait would lead to a delay of greater than 20 to 30 minutes.

The National Heart Attack Alert Program guidelines recommend that patients with the following chief complaints should have immediate assessment by triage nurses and should be referred for further evaluation[20]: • Chest pain, pressure, tightness, or heaviness; pain that radiates to neck, jaw, shoulders, back, or one or both arms • Indigestion or "heartburn"; nausea and/or vomiting associated with chest discomfort • Persistent shortness of breath • Weakness, dizziness, lightheadedness, loss of consciousness

EXAMINATION.

If the patient is not in immediate need of interventions because of circulatory collapse or respiratory insufficiency, the physician's assessment should begin with a clinical history that captures the characteristics of pain, the time of onset, and the duration of symptoms and an examination that emphasizes vital signs and cardiovascular status. This evaluation should be focused on screening for the most common life-threatening conditions: acute myocardial infarction, pulmonary embolism, and acute aortic dissection (see Table 45-1). Although information on coronary risk factors can help clinicians in the assessment of whether a patient has coronary artery disease, available data indicate that such information has limited ability to improve risk stratification of patients with acute chest pain, presumably because the probability of acute complications is dominated by other factors, such as the presence or absence of evidence of ischemia on the electrocardiogram.[3] Younger patients have a lower risk of acute coronary syndrome[21] but should be screened with greater care for histories of recent cocaine use (see Chap. 62 ).[22] ELECTROCARDIOGRAM.

The most important single source of data, the electrocardiogram, should be obtained within 10 minutes after presentation in patients with ongoing chest discomfort and as rapidly as possible in patients who have a history of chest discomfort consistent with acute coronary syndrome but whose discomfort has resolved by the time of evaluation,[19] to permit identification of patients who might benefit from primary angioplasty or thrombolytic therapy. When the electrocardiogram shows ST-segment changes or T-wave abnormalities that are consistent with the presence of ischemia and are not known to be old, discharging the patient home without further evaluation is hazardous both clinically and legally. The prevalence of acute MI is 80 percent among patients with 1 mm or more of new ST-segment elevation and 20 percent among patients with ST-segment depression or T-wave inversion not known to be old. However, if the electrocardiogram does not show changes consistent with ischemia, the risk of acute MI is about 4 percent among patients with a history of coronary artery disease and 2 percent among patients with no such history.[8] Failure to perform an electrocardiogram is one of the most important factors in malpractice losses related to patients with acute chest pain, followed by failure to interpret the electrocardiogram correctly.

Causes of Acute **Chest** **Pain** In a typical population of patients presenting for evaluation of acute **chest** **pain** in emergency departments, about 20 percent have acute MI or unstable angina.[[|5]] A small percentage have other life-threatening problems, such as pulmonary embolism or acute aortic dissection, but most are discharged without a diagnosis or with a diagnosis of a noncardiac condition. These noncardiac conditions include musculoskeletal syndromes, disorders of abdominal viscera, and psychological conditions ( [|Table 45-1] ).  Causes of Acute Chest Pain
 * Table 45-1** **-- Common Causes of Acute **Chest** **Pain****
 * **System** || **Syndrome** || **Clinical description** || **Key Distinguishing Features** ||
 * Cardiac || Angina || Retrosternal chest pressure, burning, or heaviness; radiating occasionally to neck, jaw, epigastrium, shoulders, or left arm || Precipitated by exercise, cold weather, or emotional stress; duration <2–10 minutes. ||
 * || Rest or unstable angina || Same as angina, but may be more severe || Usually <20 minutes; lower tolerance for exertion ||
 * || Acute myocardial infarction || Same as angina, but may be more severe || Sudden onset, usually lasting 30 minutes or longer. Often associated with shortness of breath, weakness, nausea, vomiting ||
 * || Pericarditis || Sharp, pleuritic pain aggravated by changes in position; highly variable duration || Pericardial friction rub ||
 * Vascular || Aortic dissection || Excruciating, ripping pain of sudden onset in anterior of chest, often radiating to back || Marked severity of unrelenting pain; usually occurs in setting of hypertension or underlying connective tissue disorder such as Marfan syndrome ||
 * || Pulmonary embolism || Sudden onset of dyspnea and pain, usually pleuritic with pulmonary infarction || Dyspnea, tachypnea, tachycardia, and signs of right heart failure ||
 * || Pulmonary hypertension || Substernal chest pressure, exacerbated by exertion || Pain associated with dyspnea and signs of pulmonary hypertension ||
 * Pulmonary || Pleuritis and/or pneumonia || Pleuritic pain, usually brief, over involved area || Pain pleuritic and lateral to midline, associated with dyspnea ||
 * || Tracheobronchitis || Burning discomfort in midline || Midline location, associated with coughing ||
 * || Spontaneous pneumothorax || Sudden onset of unilateral pleuritic pain, with dyspnea || Abrupt onset of dyspnea and pain ||
 * Gastrointestinal || Esophageal reflux || Burning substernal and epigastric discomfort, 10–60 minutes in duration || Aggravated by large meal and postprandial recumbency; relieved by antacid ||
 * || Peptic ulcer || Prolonged epigastric or substernal burning || Relieved by antacid or food ||
 * || Gallbladder disease || Prolonged epigastric, right upper quadrant pain || Unprovoked or following meal ||
 * || Pancreatitis || Prolonged, intense epigastric and substernal pain || Risk factors including alcohol, hypertriglyceridemia, and medications ||
 * Musculoskeletal || Costochondritis || Sudden onset of intense fleeting pain || May be reproduced by pressure over affected joint; occasional patients have swelling and inflammation over costochondral joint ||
 * || Cervical disc disease || Sudden onset of fleeting pain || May be reproduced with movement of neck ||
 * Infectious || Herpes zoster || Prolonged burning pain in dermatomal distribution || Vesicular rash, dermatomal distribution ||
 * Psychological || Panic disorder || Chest tightness or aching, often accompanied by dyspnea and lasting 30 minutes or more, unrelated to exertion or movement || Patient may have other evidence of emotional disorder ||

In a typical population of patients presenting for evaluation of acute chest pain in emergency departments, about 20 percent have acute MI or unstable angina.[5] A small percentage have other life-threatening problems, such as pulmonary embolism or acute aortic dissection, but most are discharged without a diagnosis or with a diagnosis of a noncardiac condition. These noncardiac conditions include musculoskeletal syndromes, disorders of abdominal viscera, and psychological conditions ( Table 45-1 ).

MYOCARDIAL ISCHEMIA OR INFARCTION (see Chap. 46 and Chap. 49 ).

The most common serious cause of acute chest discomfort is myocardial ischemia or infarction, which occurs when the myocardial oxygen supply is inadequate compared to myocardial oxygen needs. Myocardial ischemia usually occurs in the setting of coronary atherosclerosis but also may reflect dynamic components of coronary vascular resistance. Coronary spasm can occur in normal coronary arteries, or, in patients with coronary disease, near atherosclerotic plaques and in smaller coronary arterioles (see Chap. 49 ). Other, less common causes of impaired coronary blood flow include syndromes that compromise the orifices of the coronary arteries or the arteries themselves, such as syphilitic aortitis, collagen-vascular diseases, aortic dissection, myocardial bridges, or congenital abnormalities of the coronary arteries.

Ischemic chest pain also can result from any disease process that causes occlusion of a coronary artery, such as thrombosis arising at the site of a ruptured atherosclerotic plaque. Other potential causes include coronary artery emboli such as may occur in patients with infectious or noninfectious endocarditis, or a clot in the left atrium or left ventricle.

Myocardial ischemia can be precipitated by conditions that cause a mismatch between the perfusion pressure within the coronary arteries and myocardial oxygen demand, such as aortic stenosis, aortic regurgitation, or hypertrophic cardiomyopathy. Increases in heart rate can markedly exacerbate ischemia in such patients because, even while oxygen demand is rising, myocardial perfusion falls due to a reduction in the proportion of time that the heart is in diastole, thereby decreasing the available time for coronary perfusion. Other clinical conditions can worsen oxygen delivery and/or raise oxygen need, although they generally cause myocardial ischemia and chest pain only when accompanied by coronary atherosclerosis. Such conditions include anemia, sepsis, and thyrotoxicosis.

The classic manifestation of ischemia is angina, which is usually described as a heavy chest pressure or squeezing, a "burning" feeling, or difficulty breathing. It is often associated with radiation to the left shoulder, neck, or arm. It typically builds in intensity over a period of a few minutes. The pain may begin with exercise or psychological stress, but acute coronary syndromes most commonly occur without obvious precipitating factors.

"Atypical" descriptions of chest pain reduce the likelihood that the symptoms represent myocardial ischemia or injury. The American College of Cardiology and the American Heart Association (ACC/AHA) guidelines list the following as pain descriptions that are not characteristic of myocardial ischemia[9]: •   	Pleuritic pain (i.e., sharp or knife-like pain brought on by respiratory movements or cough) •   	Primary or sole location of discomfort in the middle or lower abdominal region •   	Pain that may be localized at the tip of one finger, particularly over the left ventricular (LV) apex •   	Pain reproduced with movement or palpation of the chest wall or arms •   	Constant pain that persists for many hours •   	Very brief episodes of pain that last a few seconds or less •   	Pain that radiates into the lower extremities

However, data from large populations of patients with acute chest pain indicate that acute coronary syndromes occur in patients with atypical symptoms with sufficient frequency that no single factor should be used to exclude the diagnosis of acute ischemia heart disease.[10] PERICARDIAL DISEASE (see Chap. 64 ).

The visceral surface of the pericardium is insensitive to pain, as is most of the parietal surface. Therefore, noninfectious causes of pericarditis (such as uremia) usually cause little or no pain. In contrast, infectious pericarditis nearly always involves surrounding pulmonary pleura, so that patients typically experience pleuritic pain with breathing, coughing, and changes in position. Swallowing may induce the pain because of the proximity of the esophagus to the posterior heart. Because the central diaphragm receives its sensory supply from the phrenic nerve, and the phrenic nerve arises from the third to fifth cervical segments of the spinal cord, pain from infectious pericarditis is frequently felt in the shoulders and neck. Involvement of the more lateral diaphragm can lead to symptoms in the upper abdomen and back, creating confusion with pancreatitis or cholecystitis. Pericarditis occasionally causes a steady, crushing substernal pain that is similar to that of acute myocardial infarction.[11] VASCULAR DISEASE.

Acute aortic dissection (see Chap. 53 ) usually is accompanied by sudden onset of excruciating, ripping pain, the location of which reflects the site and progression of the dissection.[12] Ascending aortic dissections tend to manifest with pain in the midline of the anterior chest, and posterior descending aortic dissections manifest with pain in the back of the chest. Aortic dissections usually occur in the presence of risk factors that include hypertension, pregnancy, atherosclerosis, and other conditions that lead to degeneration of the aortic media, such as Marfan and Ehlers-Danlos syndromes.

Pulmonary emboli (see Chap. 66 ) may be asymptomatic but often cause sudden onset of dyspnea and pleuritic chest pain.[13] Massive pulmonary emboli tend to cause severe and persistent substernal pain, which is believed to be due to distention of the pulmonary artery. Smaller emboli that lead to pulmonary infarction can cause lateral pleuritic chest pain. Hemodynamically significant pulmonary emboli may cause hypotension, syncope, and signs of right heart failure.

Pulmonary hypertension (see Chap. 67 ) can cause chest pain similar to angina pectoris, presumably because of right heart hypertrophy and ischemia.[14] PULMONARY.

Pulmonary conditions that cause chest pain usually produce dyspnea and pleuritic symptoms, the location of which reflect the site of pulmonary disease.[15] Tracheobronchitis tends to be associated with a burning midline pain,[16] whereas pneumonia can produce pain over the involved lung. The pain of a pneumothorax is sudden in onset and is usually accompanied by dyspnea. GASTROINTESTINAL.

Irritation of the esophagus by acid reflux can produce a burning discomfort that is exacerbated by alcohol, aspirin, and some foods. Symptoms often are worsened by a recumbent position and relieved by sitting upright and by acid-reducing therapies.[17] Esophageal spasm can produce a squeezing chest discomfort similar to that of angina.[18] Mallory-Weiss tears of the esophagus can occur in patients who have had prolonged vomiting episodes.

Chest pain due to ulcer disease usually occurs 60 to 90 minutes after meals and is typically relieved rapidly by acid-reducing therapies. This pain is usually epigastric in location but can radiate into the chest and shoulders.

Cholecystitis produces a wide range of pain syndromes and usually causes right upper quadrant abdominal pain. Chest and back pain due to cholecystitis is not unusual, however. The pain is often described as aching or colicky. Pancreatitis typically causes an intense aching epigastric pain that may radiate to the back. Relief through acid-reducing therapies is limited. MUSCULOSKELETAL AND OTHER CAUSES.

Chest pain can be caused by musculoskeletal disorders involving the chest wall, such as costochondritis, or by conditions affecting the nerves of the chest wall, such as cervical disc disease or herpes zoster. Musculoskeletal syndromes causing chest pain are often induced by direct pressure over the affected area or by movement of the patient's neck. The pain itself can be fleeting, or a dull ache that lasts for hours.

Panic syndrome is a major cause of chest discomfort among emergency department patients.[19] The symptoms typically include chest tightness, often accompanied by shortness of breath and a sense of anxiety, and generally lasting for 30 minutes or more. CLINICAL EVALUATION.

When evaluating patients with acute chest pain, the clinician must address a series of issues related to prognosis and immediate management. Even before trying to arrive at a definite diagnosis, high-priority questions include the following: •   	Clinical stability: Is the patient in need of immediate treatment of circulatory collapse or respiratory insufficiency? •   	Immediate prognosis: If the patient is currently clinically stable, what is the risk that the patient has a life-threatening condition, such as an acute coronary syndrome, pulmonary embolism, or aortic dissection? •   	Safety of triage options: If the risks of life-threatening conditions are low, would it be safe to discharge the patient for outpatient management, or should the patient have further testing and/or observation to guide management?

Previous 	Next DIFFERENTIAL DIAGNOSIS.

Chest pain that occurs after protracted vomiting can be due to the Mallory-Weiss syndrome (i.e., a tear in the lower portion of the esophagus). Pain that occurs while the patient is bending over is often radicular and can be associated with osteoarthritis of the cervical or upper thoracic spine. Chest pain occurring on moving the neck can be due to a herniated intervertebral disc. ESOPHAGEAL AND OTHER GASTROINTESTINAL PAIN

Substernal and epigastric discomfort after swallowing can be caused by esophageal spasm or esophagitis, often with acid reflux, with or without a hiatal hernia.[17][18][19] These conditions can also be associated with substernal or epigastric burning pain that is brought on by eating or by lying down after meals and that can be relieved by antacids. Pain due to esophageal spasm has many of the features of and may be difficult to differentiate from angina pectoris. A history of acid reflux into the mouth (water brash) and/or dysphagia can be a useful diagnostic clue pointing to esophageal disease. The chest discomfort secondary to esophageal reflux is most common after meals, occurs in the supine position or on bending, and can be relieved by nitroglycerin.

The discomfort produced by peptic ulcer disease is characteristically located in the mid-epigastrium. It can also resemble angina pectoris, but its characteristic relationship to food ingestion and its relief by antacids are important differentiating features. The pain of acute pancreatitis, like that of acute myocardial infarction, may be predominantly in the epigastrium. However, unlike the pain of myocardial infarction, pancreatic pain is usually transmitted to the back, is position sensitive, and can be relieved in part by learning forward.[16] OTHER CAUSES

The chest discomfort of unstable angina[12] and acute myocardial infarction (see Chap. 46 and Chap. 49 ) is similar in quality, location, and character to that of chronic stable angina pectoris; however, it usually radiates more widely than does chronic stable angina, is more severe, and therefore is generally referred to by the patient as true pain rather than discomfort. The development of pain in patients with these conditions is usually unrelated to unusual effort or emotional stress, often with the patient at rest or even sleeping. Characteristically, nitroglycerin does not provide complete or lasting relief. The chest discomfort of pulmonary hypertension (see Chap. 67 ) may be identical to that of typical angina[20]; it is caused by right ventricular ischemia or dilation of the pulmonary arteries.

Acute pericarditis (see Chap. 64 ) is frequently preceded by a history of a viral upper respiratory infection. The inflammation causes pain that is sharper than anginal discomfort, is more left sided than central, and is often referred to the neck, upper shoulders, and back. The pain of pericarditis lasts for hours and is little affected by effort but is often aggravated by breathing, turning in bed, swallowing, or twisting the body; unlike the discomfort produced by ischemia, the pain of acute pericarditis may lessen when the patient sits up and leans forward.

Aortic dissection (see Chap. 53 ) is suggested by the sudden development of persistent, very severe pain with radiation to the back and into the lumbar region, often in a patient with a history of hypertension. An expanding thoracic aortic aneurysm may erode the vertebral bodies and cause localized, severe, boring pain that may be worse at night.

Chest-wall pain due to costochondritis or myositis is common in patients who present with fear of heart disease.[21] It is associated with local costochondral and muscle tenderness, which can be aggravated by moving or coughing. Chest-wall pain can also accompany chest injury. In patients with the Tietze syndrome, the discomfort is localized to swollen costochondral and costosternal joints, which are painful on palpation. When herpes zoster affects the left chest, it can mimic myocardial infarction. However, its persistence, its localization to a dermatome, the extreme sensitivity of the skin to touch, and the appearance of the characteristic vesicles allow recognition of this condition. The preeruptive stage of herpes zoster can mimic myocardial ischemia as a tight localized band across the chest.

The pain of pulmonary embolism (see Chap. 66 ) usually commences suddenly and in patients who are at rest, and it is accompanied by shortness of breath. It is typically described as tightness in the chest and is accompanied or followed by pleuritic chest pain (i.e., sharp pain in the side of the chest that is intensified by respiration or cough). Functional or psychogenic chest pain (see Chap. 84 ) can be one feature of an anxiety state called Da Costa syndrome or neurocirculatory asthenia.[22][23][24] It differs from angina pectoris in that it is usually localized to the cardiac apex and consists of a dull, persistent ache that lasts for hours and is often accentuated by or alternates with attacks of sharp, lancinating stabs of inframammary pain of 1 or 2 seconds' duration. The condition may occur with emotional strain and fatigue, bears little relation to exertion, and may be accompanied by precordial tenderness. Attacks can be associated with palpitation, hyperventilation, numbness and tingling in the extremities, sighing, dizziness, dyspnea, generalized weakness, faintness, severe fatigability, and a history of panic attacks and other signs of emotional instability or depression. The pain may not be completely relieved by any medication other than analgesics, but it is often attenuated by many types of interventions, including rest, exertion, tranquilizers, and placebos. Patients with Da Costa syndrome usually are young (<40 years), are female, and have high scores on depression and anxiety scales.[24] RELIEF OF PAIN

Rest and sublingual nitroglycerin characteristically relieve the discomfort of chronic stable angina in 1 to 5 minutes. If more than 10 minutes transpire before relief, the diagnosis of chronic stable angina becomes questionable and instead unstable angina, acute myocardial infarction, or pain not caused by myocardial ischemia at all is the cause. Although nitroglycerin commonly relieves the pain of angina pectoris, response to this drug is nonspecific, since the discomfort caused by esophageal spasm and esophagitis can also be relieved. Angina pectoris is alleviated by quiet standing or sitting; sometimes resting in the recumbent position does not relieve angina. Chest pain secondary to acute pericarditis is characteristically relieved by leaning forward, whereas pain that is relieved by food or antacids may be due to peptic ulcer disease or esophagitis. Pain that is alleviated by holding the breath in deep expiration is commonly due to pleuritic inflammation. Some patients with upper gastrointestinal disease or anxiety report relief of symptoms after belching. CHEST PAIN IN WOMEN (see Chap. 73 ).

Chest discomfort that is atypical for angina pectoris is more common in women than in men, perhaps because of the higher prevalence of vasospastic and of microvascular angina and nonischemic causes of chest pain in women.[25][26][27] Women with epicardial coronary artery disease more often report chest discomfort at rest, during sleep, or during mental stress than do men. ACCOMPANYING SYMPTOMS.

The physician should always be concerned about the patient with the combination of severe chest discomfort and profuse sweating. This combination frequently signals a serious disorder, such as acute myocardial infarction but also acute pulmonary embolism or aortic dissection. Severe chest pain accompanied by nausea and vomiting is also often due to myocardial infarction. The latter diagnosis, as well as pneumothorax, pulmonary embolism, or mediastinal emphysema, is suggested by pain associated with shortness of breath. Chest pain accompanied by palpitation may be due to the acute myocardial ischemia precipitated by a tachyarrhythmia-induced increase in myocardial oxygen consumption in the presence of coronary artery disease. Chest pain accompanied by hemoptysis suggests pulmonary embolism with infarction or lung tumor, whereas pain accompanied by fever occurs in patients with pneumonia, pleurisy, and pericarditis. Functional pain is commonly accompanied by frequent sighing, anxiety, or depression.