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1. Thoracic pain of cardiovascular origin
2. Thoracic pain of pleuropulmonary origin
3. Thoracic pain of digestive origin
4. Thoracic pain coming from the thoracic wall
5. Thoracic pain of neurological origin
6. Thoracic pain and anxiety

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1 - Thoracic pain of cardiovascular origin:

a - The angina pectoris (or “angor”)

It corresponds to the following characteristics:

- The medical consultation is usually made outside pains;

- The pain has a relationship with the exercise, or equivalents of exercise;

- The pain yields to the stop of the exercise or more quickly under trinitroglycerine;

- Sometimes the pain in the chest is spontaneous;

- This pain is typically localized in the middle of the chest, under the sternum or sometimes at the epigastrium hollow;

- It usually looks like a burden on the thorax;

- This pain can radiate at the level of the jaws, of the two arms;

- It lasts as a rule some minutes.

b - The myocardial infarction

- It often complicates an angor or can be inaugural;

- The pain looks like an intense, prolonged angor crisis and not yielding to the trinitroglycerine;

- The accompanying signs are, according to the localization: the digestive signs (nauseas, vomiting, diarrhoea);

- Its duration is very variable, capable of lasting from some minutes to several hours.

c - The aortic dissection

- It very frequently occurs in the aged subject with a badly controlled HBP, but sometimes in the predisposed young subject;

- The pain is brutal and violent, immediately maximal, with a variable and classically migratory place;

- The B.P is measured on the 2 arms and the palpation of the pulses show an asymmetry;

- The physician searches for an aortic insufficiency.

d - The acute pericarditis

It is characterized by:

- A pain increased by the leaning forward position and by the cough;

- A cough, a shortening of breath, a fever in a viral context;

- The physician notes a pericardial friction rub in 50% of the cases onauscultation of the heart.

2 - Thoracic pain of pleuropulmonary origin

Generally, the pain comes from the pleura which is a tissue surrounding the lung.

a - Pulmonary Embolism

- The diagnosis is difficult to make, and always requires a body of arguments: phlebitis context, pain at the basis of the thorax, shortening of breath, sputum of blood, discreet fever, tachycardia...

- The physician must search for a phlebitis.

b - Pneumothorax (presence of air in the pleura)

It is suspected facing:

- A very variable pain of the pleura and shortening of breath;

- The frequent occurrence during an exercise.

c - Pneumomediastinum (presence of air in the thorax)

It is suspected facing:

- A pain under the sternum or at the basis of the thorax;

- The presence of air under the skin at the level of the thorax, susclavicular and neck hollows.

d - Infection of the pleura: pleurisy

Pleurisy is suspected facing a variable pleural pain and shortening of breath.

e - Pleural tumour: pleural pain

f - Pulmonary infection: Infectious pneumopathy

It is characterized by the occurrence of a pain at the basis of the thorax in an infectious context (fever, chills…).

g - Pulmonary hypertension

3 - Thoracic pain of Digestive Origin

a - Oesophageal origin

These pains sometimes take a similar character to the one of the angina pectoris, from which they differ by the existence of a painful deglutition, of an acidic taste regurgitation, the positional triggering, especially in the leaning forward position.

* The gastro-oesophageal reflux

The thoracic pain is localized behind the sternum, in the centre of the thorax; it looks like a burn and often comes with an acidic taste in the mouth. This symptom is predominant. The digestive endoscopy is achieved in order to see the stomach (and the oesophagus) and more often the pHmetry permits the diagnosis.

* Boerhaave’s syndrome or non-traumatic rupture of the oesophagus

The pain evolves by severe crises at the level of the basis of the thorax or at the pit of the stomach, associated to vomiting and signs of haemorrhagic shock.

b - Abdominal origin

The liver and gallbladder ulcerous pathology and the acute pancreatitis can give a thoracic pain, as well as the distension of the left colic angle. It is necessary to search for the specific characteristics of every pain. The exams asked by the physician are function of each pathology.

4 - Thoracic pain coming from the thoracic wall

The palpation or the mobilization of the thoracic wall reproduce the pains.

The rib fractures, the infections of the bone (osteitides), the Still’s disease (in the rheumatoid arthritis, a thoracic pain must have a pleurisy searched for) can give pains of the thoracic wall (parietal pains).

5- Thoracic pain of Neurological Origin

A compression of the root of a nerve can induce a pain of the thorax.

The diagnosis calls on the simple x-ray of the vertebras responsible for the compression of the nerve, the scanner and currently the nuclear magnetic resonance imaging (MRI) of the sick area.

The zona in its preeruptive phase can also provoke a pain in the thorax.

6- Thoracic pain and Anxiety

It is evidently a diagnosis of elimination. It characteristically occurs in the less than 30 year-old woman and its features are:

- Absence of triggering factor;

- No nocturnal awakening;

- Very limited site or on the contrary spreading beyond the thorax;

- Accompanying functional signs.

Several pathological frameworks have been identified: fibromyalgia syndrome, hyperventilation syndrome, panic crisis, neurasthenia...

Nevertheless, these diagnoses must never formally turn down a more serious diagnosis (myocardial infarction for example).