CHEST PAIN CAUSED BY MYOCARDIAL ISCHAEMIA

Chest pain associated with heart disease is called angina pectoris. Most patients with angina have a narrowing or stenosis in one or

PERICARDITIS

Pericardial pain is usually described as a constant soreness behind the breast bone and that often gets much worse if the patient takes a deep breath. Unlike the pain of angina or myocardial infarction, pericarditic pain is related to movement, typically worse on leaning forward, but not to physical exertion. It sometimes radiates to the tip of the left shoulder.

MUSCULOSKELETAL CHEST PAIN

Characteristically, it tends to be an aching pain, the onset of which may relate to a particular twist or movement. There is often localised tenderness, particularly over the costal cartilages. This is sometimes called costochondritis or Tietze syndrome.

DISSECTING AORTIC ANEURYSM

Dissecting aneurysm of the thoracic aorta causes a rare form of chest pain that usually starts as a ‘tearing’ sensation, often felt most between the shoulder blades or in the back. The pain is usually severe and persistent and may be mistaken for the pain of myocardial infarction.

OTHER CHEST PAINS

Other chest pains that may masquerade as cardiac pain include the pain of pleurisy, of an acute pneumothorax or of shingles.

PALPITATION

Palpitation is defined as abnormal awareness of the heart beat. It is often helpful to ask the patient to tap out the heart rhythm on the table.

SYNCOPE (FAINTING, BLACKOUTS)

Syncope is defined as loss of consciousness resulting from a transient failure of blood supply to the brain. The main differential diagnosis is from epilepsy. The common causes of syncope are simple fainting (vasovagal syncope) and its variants such as micturition syncope, postural hypotension, vertebrobasilar insufficiency and cardiac arrhythmias, particularly intermittent heart block.

In fainting, loss of consciousness is seldom abrupt; the patient looks pale both before and immediately afterwards. In contrast, syncope caused by heart block is often sudden, unheralded and complete. The patient looks pale while collapsed; recovery (which is often equally sudden) may be heralded by a pink flush. Vertebrobasilar insufficiency is common in elderly patients: there may be restricted neck movement and active or passive movements of the neck may precipitate symptoms.

CLAUDICATION

Intermittent claudication is the name given to a condition in which the patient experiences pain in one or both legs on walking and which eases up when the patient rests. The pain is usually an aching pain felt in the calf, thigh or buttocks.

BRACHIAL PULSE

Use the thumb of the right hand, applied to the front of the elbow just medial to the biceps tendon with the fingers cupped round the back of the elbow. Figure 6.2 illustrates the different pulse waveforms.

Fig. 6.2 Different pulse waveforms are associated with different cardiac or vascular abnormalities.

CAROTID PULSE

The best way to feel the patient’s right carotid artery is to locate the tip of the examiner’s left thumb against the patient’s larynx (Fig. 6.3). In severe aortic stenosis, there is characteristically a slow rising carotid pulse. Another sign best appreciated at the carotid is the jerky pulse of hypertrophic cardiomyopathy.

Fig. 6.3 Palpation of the carotid artery using the thumb.

FEMORAL PULSE

This is best examined by placing the thumb or finger directly above the superior pubic ramus and midway between the pubic tubercle and anterior superior iliac spine.

POPLITEAL PULSE

The popliteal pulse is readily felt by compressing it against the posterior surface of the distal end of the femur. The patient lies flat with the knee slightly flexed. The fingers of one hand are used to press the tips of the fingers of the other hand into the popliteal fossa to feel the popliteal artery against the back of the knee joint.

DORSALIS PEDIS AND TIBIALIS POSTERIOR PULSES

The dorsalis pedis pulse is felt with the fingers aligned along the dorsum of the foot lateral to the extensor hallucis longus tendon; the tibialis posterior pulse is felt with the fingers cupped round the ankle just posterior to the medial malleolus.