There are a few medical texts that physicians set aside as timeless works for frequent reference and review. These are the books that young physicians use to acquire core knowledge and that mature physicians use to enrich their clinical expertise. Such a text is “Chest Pain” →, a work conceived by Drs. Willis Hurst and Douglas Morris as an outgrowth of “early morning sessions with the medical house staff at Emory University Hospital.”
The unusual title, “Chest Pain” →, was chosen by Dr. Hurst specifically to convey the purpose of the text, which is to inspire the reader to make the final diagnosis. In patients' parlance, “chest” refers to any part of the body above the waist, and “pain” can mean anything from pressure or indigestion to a patient's description of a “shoe box in the chest”. The arrow (→) signifies that a differential diagnosis must follow. Terms such as typical or atypical chest pain, or noncardiac pain, are not diagnoses and do little to clarify the cause of the symptom to the physician or the patient. Instead, they should be seen as useful observations that beget more questions. So important is this point that Dr. Hurst prefaces each major section of the text with his explanation of the title.
In all, there are 13 disease categories that the editors have designated as causes for chest pain, ranging from dermatologic, neurologic, pulmonary, and cardiovascular, to emotional. The authors of these chapters come from the appropriate subspecialties, and each chapter is written in a similar, concise format: starting with the Clinical Setting, it progresses to Characteristics and Location of the Pain, Differential Diagnosis, and Etiology and Basic Mechanism, then ends with Treatment. With this arrangement, the reader is given a reasonably complete, if not exhaustive, review of the topic, which enables the novice physician to learn and the experienced physician to master the subject in short order. Some readers might notice omissions from the compendium of chest pain topics. For me, it was chest pain caused by paraesophageal hernia with gastric volvulus, a rare condition with dramatic and sometimes fatal consequences. Incidentally, I must commend the editors for restricting the authors to pertinent (not superfluous) references, and for their excellent cross-referencing within the text.
In this day of technical testing, clinical pathways, and ever-changing paradigms set by clinical trials, there is a tendency for physicians to prescribe the most recent therapy and to feel self-satisfied about having done so. Distinguishing between coronary and noncoronary chest pain has become a burden rather than a clinical challenge, and is sometimes handled by relegating the patient to a chest pain clinic. If the patient is discharged from the chest pain clinic and not admitted for acute coronary syndrome, he frequently leaves the medical encounter with no clear understanding of his symptom, since a final diagnosis often has not been made. “Chest Pain” → is a text to help the physician complete the diagnosis to both his own satisfaction and that of the patient. It is a book that I will keep in my personal medical library.