Atypical Presentation of Illness: Diagnosing the Cause of Chest Pain

Atypical presentations of illness in older patients represent a challenge for nurses because their diagnosis is rarely considered in medical training, thus leading to difficulties in managing individuals’ conditions. Such presentations are considered ‘atypical’ due to the lacking signs and symptoms that characterize a condition and its further diagnoses. Nevertheless, in older patients, atypical representations are common; for instance, a significant change in functional ability or behavior can be a sign of a new and serious condition. This means that the atypical presentation of illness can lead to missed diagnoses, poor patient outcomes, and the subsequent treatment of conditions.

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With age, the prevalence of atypical illness presentation increases, with other common risks, including multiple medical conditions, multiple medications, as well as functioning or cognitive impairment (Perissinotto & Ritchie, 2014). Reflecting on cases of patients with atypical presentations of illness, the example of a female with atypical chest pain signs will be discussed. The patient was sixty-five years old and was taking several medications at the same time. The typical presentation of angina, which is associated with chest pain, implies the sensation of pressure, heaviness, tightness, and burning in the chest. These sensations radiate to the shoulders, neck, inner arm, and jaw; the overall discomfort can be relatively predictable. The chest pain lasts between three and fifteen minutes and reduces when stressors are gone or when medication is administered.

While the mentioned signs and symptoms are associated with the typical presentation of angina, the patient presented to the acute care setting with the atypical, non-cardiac presentation of chest pain. She reported a random onset of the pain that could last hours in some cases and seconds in others. Therefore, the patient thought that the pain was concerning due to its randomness and the absence of triggers that increase the likelihood of occurrence. The description of pain represented in the patient was sharp and knife-like, pulsating, pricking, and choking. In regards to the location of the pain, the patient reported it being positional and involving chest wall, being tender to palpation, inflammatory in some cases, with highly variable patterns of radiation. In terms of the response to nitroglycerin, the patient showed different responses.

To diagnose the patient with atypical chest pain presentation, determining whether the pain was anginal, atypical, or non-anginal was essential. It was also necessary for determining the patient’s cardiac risk. As mentioned by Cayley (2005), “the Rouan decision rule is recommended to help predict which patients are at higher risk of myocardial infarction […] while the Diehr diagnostic rule is recommended to predict the likelihood of pneumonia based on clinical findings” (p. 2014). For the older patient who presented with chest pain, an ECG evaluation was performed to determine the elevation of ST segments, Q waves, and conduction defects. Also, the Duke treadmill score was implemented for helping predict the long-term prognosis for the patient.

In summary, the patient’s history was evaluated, with specific attention given to the location, duration, and quality of chest pain as well as both alleviating and aggravating factors. To overcome the challenge of atypical symptom representation, the presence of co-morbidities was assessed (Ricci, Cenko, Varotti, Puddu, & Manfrini, 2016). It was found that the patient had diabetes and had a higher likelihood of myocardial infarction, which concluded the likely diagnosis of acute coronary syndromes that would be managed further.


Cayley, W. (2005). Diagnosing the cause of chest pain. American Family Physician, 72(10), 2012-2021.

Perissinotto, C., & Ritchie, C. (2014). Atypical presentations of illness in older adults. In A. A. Williams, A. Chang, C. Ahalt, H. Chen, R. Conant, S. Landefeld, C. Ritchie & M. Yukawa (Eds.), Current diagnosis & treatment: Geriatrics (pp. 78-80). New York, NY: McGraw-Hill Education.

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Ricci, B., Cenko, E., Varotti, E., Puddu, P., & Manfrini, O. (2016). Atypical chest pain in ACS: A trap especially for women. Current Pharmaceutical Design, 22(25), 3877-3884.

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