Chest Pain

History and Physical Examination

Despite major innovations in diagnostic technology and advances in medical therapy, a well-performed history and physical examination remain the cornerstone of good patient care. In addition to providing important clues about a patient's illness, a thorough evaluation helps to direct further diagnostic testing and therapy. It also provides the physician an opportunity to establish rapport with the patient; strong physician-patient relationships establish trust and help to ensure compliance with treatment regimens. Conversely, an inadequate or poorly obtained history may trigger inappropriate or incomplete testing and contribute to additional morbidity and mortality.

The cardinal symptoms of heart disease include chest pain, dyspnea, and palpitations. These symptoms will be discussed in this and the following sections. A thorough history of each symptom includes information regarding symptom duration, frequency, quality, severity, aggravating or alleviating factors, and associated symptoms. With regard to chest pain, location and radiation are also important features.

Clinical Manifestations

History

Angina is the cardinal symptom of coronary artery disease (CAD) and results from inadequate oxygen delivery to the myocardium. It is usually an uncomfortable sensation rather than a pain, and may he described as:

• an ache
• hearthurn
• indigestion
• a choking sensation
• constriction
• pressure

The symptom is generally substernal in location, but may radiate or localize to the precordium, neck, jaw, shoulders, anns, or epigastrium. Patients with angina often use a clenched fist to indicate the site of discomfort (Levine's sign). Anginal pain is generally triggered by exertion, relieved by rest, and resolves more rapidly (within 1 to 5 minutes) with sublingual nitroglycerin.

Other precipitating factors include cold weather, walking on inclines, emotional upset, fright, and the postprandial state. Occasionally, it may occur spontaneously in the early morning hours.
Anginal chest pain may occur in several patterns:

• Stable angina is angina that occurs in a welldefined, reproducible pattern-usually on exertion.
  
• Unstable angina refers to angina that is new, occurs at rest, or occurs more frequently than the person's usual angina.
  
• The pain of a myocardial infarction is usually more intense and longer lasting than angina, radiates more widely, and is often accompanied by dyspnea, diaphoresis, palpitations, nausea, and vomiting.