Chest Pain

Chest Pain is a common yet difficult condition to diagnose. Most chest pains or discomforts are benign, however, some may be a harbinger of serious cardiac emergencies. It is often alarming as the 1st episode may result in instantaneous collapse and sudden death.

About 2/3rds of chest pain are non-organic. Non-organic means not due to heart, lungs, esophagus diseases. About 30 % are due to muscular or rib conditions and about 10% are due to esophagus related disorders. Serious chest pains only form about 10% of the patients attending a doctor. However as the 1st episode itself may be due to a “heart attack” or Acute Myocardial Infarction, all chest pain cases need to be dealt with in detail. The episodes which also include heart attacks, unstable anginas or similar pains due to suspected heart ischemia are clubbed together as Acute Coronary Syndrome or ACS. This helps in deciding which patients need to be admitted or observed.

Ischemic chest pains may be recurrent, appear after a certain quantity of physical exercise, get relieved by rest or nitrate tablets under the tongue are called angina or stable angina.

The ones due to Myocardial Infarctions may be difficult to describe, occur only once or a few times in the life of an individual. These may spread to one or both arms, shoulder/shoulders or jaws. This can be accompanied by nausea, vomiting, collapse, profuse sweating or fatigue. These increase over minutes to hours. In case a myocardial infarction is suspected, aspirin in a dose of about 300 mg is given to the patient to be chewed. In case blood pressure is stable, he or she is given a sublingual nitrate and oxygen is administered if blood levels are low or not available.

Chest pains which have increased in frequency, occur at night, have become more severe or longer lasting, occur at night may suggest Unstable Angina.

Women may describe the pain as more severe and sharp compared to men.

The diagnosis of most of these cases is based on meticulous history, ECGs, Cardiac enzymes and serial observations of these. Based only on clinical evidence the diagnosis may often be wrong.

In cases of chronic stable angina, stress testing, isotope scan (Stress Thallium), provocation tests or angiography may be required.

It is important to know the risk factors for the likelihood of ischemic disease. These are age, male sex, smoking, high blood pressure, diabetes, high levels of lipids in the blood, sedentary lifestyle etc. The more the risk factors, the more likely is the occurrence of ischemic heart disease.

Non-organic cases may be due to anxiety, panic disorders etc. Musculo-skeletal causes include costochondritis (inflammation of rib cartilages). Acid peptic disease, diseases of lungs are also common but relatively simpler to diagnose. Very severe tearing pain may rarely be due to a tear in the aorta (called aortic dissection) and in hospitalized patients, Pulmonary Thromboembolism may be the underlying cause. These are rare but result in fatalities if remain undiagnosed.

Headache

Headache is one of the commonest symptoms causing significant distress to patients. Chronic headaches may recur for years and cause economic, social, psychological and physical issues. 90% of the headaches are benign.

Headache includes pain in the area above the neck including the face. Chronic headaches are common and affect about 40 to 45 % of the population. Chronic headaches may be called tension headaches, migrainous or cluster headaches. The pain may be cutting, shearing, burning, dull or sharp, deep or superficial, throbbing, waxing or waning and of many other types.

Tension headaches often produce a band like sensation or tightness in the head. These are not due to tension in the muscles as is commonly believed. These are also not due to “ Tension or Stress”. The exact mechanism is not clear.

Migrainous headaches are usually throbbing, maybe in one half or both sides, usually last for a few hours to 1 or 2 days, and may be relieved by vomiting or sleep. A patient may know few hours before the onset of a headache that he or she is going to get one. These may affect up to 40 % of the population. These can be effectively prevented and decreased by medicines in most patients.

Cluster headaches are rare (about 1% of all headaches), occur in groups occurring daily for a few weeks to months, last for lesser duration (few minutes to 2-3 hours) and are throbbing. These are severely disabling in nature.

Sinus headaches are usually localized to the area around sinuses. These may be aggravated by sniffing or deep breathing.

Headaches due to meningeal irritation or infection are rare but serious and if not treated rapidly may be fatal. These are usually localized to the back of the head and upper part of the neck up to the shoulders. These may be aggravated by bending the neck forwards. These are often severe, occur with fever or in epidemics, have associated vomiting and cause prostration very early.

Headaches due to brain tumours are often deep-seated, worse at night and worsen with time over days, weeks and months. Associated vomiting (forceful and often sudden) are common.

Most fevers can have headaches associated with them. The headache may increase and or decrease with temperature.

Dangerous Signs of Headaches :

Severe headache coming on suddenly and worsening over seconds to minutes and occurring for the 1st time in life may suggest a bleeding in the brain. Headaches progressively worsening may be due to tumours. Headaches with neurological signs i.e paralysis, double vision, loss of vision or hearing on one side, fits or changes in the level of consciousness, change in voice, inability to speak or comprehend etc usually mean organic (affecting structures of the brain) headaches.

Psychiatric conditions like depression may cause headaches or headaches may cause depression. Headaches may be a side effect of various drugs.

The diagnosis of headaches is usually by a detailed history and relevant clinical examination. X-Ray Skull, CT Scan of the brain and neck spine or MRI may be required for the diagnosis of brain tumours or bleeding.

Chronic headaches are difficult to treat and test the patience of the doctors and the patients both.