Chamberlain's Symptoms and Signs in Clinical Medicine, An Introduction to Medical Diagnosis

Andrew R Houghton, David Gray

• Publisher: CRC Press
• Year: 2010
• ISBN:
  9781482213782
• Edition: 13
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

A classic text, Chamberlain's Symptoms and Signs in Clinical Medicine has been providing students and professionals with a detailed and well-illustrated account of the symptoms and signs of diseases affecting all the body systems since the first edition published in 1936. Now completely rewritten by a new team of authors selected for their experien

B INDIVIDUAL SYSTEMS

Chapter 7 The cardiovascular system

Chapter 8 The respiratory system

Chapter 9 The gastrointestinal system

Chapter 10 The renal system

Chapter 11 The genitourinary system

Chapter 12 The nervous system

Chapter 13 Psychiatric assessment

Chapter 14 The musculoskeletal system

Chapter 15 The endocrine system

Chapter 16 The breast

Chapter 17 The haematological system

Chapter 18 Skin, nails and hair

Chapter 19 The eye

Chapter 20 Ear, nose and throat

Chapter 21 Infectious and tropical diseases

7 CARDIOVASCULAR SYSTEM

Andrew R Houghton and David Gray

INTRODUCTION

There is a just small number of presenting symptoms of cardiovascular disease, namely chest discomfort, breathlessness, palpitation, dizziness and syncope, and peripheral oedema. There are, however, a multitude of physical signs, but these are relatively straightforward to interpret as long as you bear in mind the underlying cardiovascular physiology and pathophysiology.

CLINICAL HISTORY

Presenting complaint

Chest discomfort

Patients with angina often say that the symptom they experience in the chest is not a pain but a feeling of discomfort. It’s important to recognize this – if you only ask the direct question ‘Do you get chest pain?’, and the patient answers ‘No’, you might move on and miss a vital part of the patient’s history.

IMPORTANT

If you must ask a leading question, enquire about chest discomfort rather than chest pain.

There are many different causes of chest discomfort, each of which has its own key characteristics (Table 7.1). Enquire about the following features:

• location and radiation:

• central (retrosternal), radiating to the arms, neck and jaw in angina and myocardial infarction

• retrosternal in gastro-oesophageal reflux and oesophageal spasm

• between the shoulder blades (interscapular) in aortic dissection

• tends to be localized with musculoskeletal or pleuritic pain, although the pain of massive pulmonary embolism can mimic that of angina

• character:

• tight, heavy, crushing in angina or myocardial infarction

• ‘tearing’ in aortic dissection

• sharp/stabbing with pleuritic pain (e.g. pulmonary embolism)

• sharp or ‘raw’ with pericarditis

• sharp/stabbing or dull with musculoskeletal pain

• severity:

• graded by the patient on a scale of 0–10, where 10 represents the worst pain ever

• duration and onset:

• angina – onset with exertion/emotional stress and usually lasting less than 10 minutes

• myocardial infarction – onset often at rest, lasting more than 10 minutes

• pulmonary embolism – pleuritic chest pain of sudden onset

• aortic dissection – sudden onset

• musculoskeletal – may be of sudden onset (e.g. with movement) and lasts a few seconds, or be more gradual and chronic (e.g. costochondritis)

• precipitating, exacerbating and alleviating factors:

• angina – brought on by exertion/emotional stress, particularly in cold windy weather and/or after a heavy meal, and rapidly relieved by rest or sublingual glyceryl trinitrate (GTN)

• myocardial infarction – pain continues despite resting or using GTN

• pericarditis – exacerbated by lying flat and respiration, relieved by sitting upright and leaning forwards

• pleuritic pain – worsened by inspiration and coughing

• musculoskeletal – worsened by movement

Table 7.1 Common causes of chest discomfort and their characteristic features

System	Cause	Characteristic features
Cardiovascular	Angina	Tight or heavy central chest discomfort, radiating to left and/or right arm, neck and jaw, worsened by exertion or stress and relieved with glyceryl trinitrate. Associated with breathlessness
	Myocardial infarction	Similar in character to angina but usually more severe and not relieved with glyceryl trinitrate. Often occurs at rest. Associated with breathlessness, sweating, nausea and vomiting
	Pericarditis	Chest pain may be sharp or ‘raw’. Exacerbated by lying flat and respiration. Eased by leaning forwards. May be associated with breathlessness and fever
	Aortic dissection	Severe ‘tearing’ interscapular pain. May be associated with ischaemia in other regions if the blood supply is compromised, e.g. stroke (cerebrovascular ischaemia), abdominal pain (mesenteric ischaemia), paraplegia (spinal cord ischaemia)
Respiratory	Pleuritic pain (e.g. pulmonary embolism)	Sharp/stabbing pain, exacerbated by inspiration. Associations depend upon underlying cause (e.g. breathlessness and haemoptysis in pulmonary embolism, productive cough and fever in pneumonia)
Gastrointestinal	Gastro-oesophageal reflux	A burning discomfort rising from the stomach or lower chest up towards the neck. Exacerbated by bending over, straining or lying down, especially after a meal. Associated with waterbrash
	Oesophageal spasm	Central chest discomfort that can mimic angina, even being relieved by glyceryl trinitrate (although usually taking longer than 5 minutes). Unlike angina, it is unrelated to exertion and often occurs at rest
Musculoskeletal	E.g. costochondritis (Tietze’s syndrome), rib fracture, malignant chest wall involvement	Localized chest discomfort which may be of sudden onset (e.g. with movement) and lasts a few seconds, or be more gradual and chronic (e.g. costochondritis). Usually exacerbated by movement
Dermatological	Shingles (herpes zoster)	Usually unilateral in a nerve root distribution and with a blistering rash

• associated symptoms

• angina – breathlessness (which may be more of a feature than chest discomfort)

• myocardial infarction – breathlessness, sweating, nausea and vomiting

• pericarditis – breathlessness, fever

• pulmonary embolism – breathlessness, haemoptysis

• pneumonia – breathlessness, productive cough, fever

• gastro-oesophageal reflux – waterbrash.

The characteristic features of the common causes of chest discomfort are discussed in more detail under the individual sections for angina (p. 65), acute coronary syndromes (p. 66), pericarditis (p. 76), aortic dissection (p. 67), pulmonary embolism (p. 106), pneumothorax (p. 106) and dyspepsia (p. 109).

Breathlessness

A degree of breathlessness (dyspnoea) is normal on heavy exertion, but breathlessness becomes abnormal when it is disproportionate to the level of activity undertaken. As with chest pain, you should ask about:

• severity (heart failure symptoms can be graded using the New York Heart Association (NYHA) functional classification, see Table 7.2)

• duration and onset

• precipitating, exacerbating and alleviating factors

• associated symptoms (e.g. chest discomfort).

Table 7.2 The New York Heart Association (NYHA) functional classification of heart failure symptoms

NYHA class	Description
Class I	No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea
Class II	Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea
Class III	Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnoea
Class IV	Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased

From: The Criteria Committee of the New York Heart Association. 1994. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels, 9th edn. Boston, MA: Little, Brown & Co, 253...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Instructions for companion website
• Preface
• List of contributors
• Chamberlain and his textbook of symptoms and signs
• Acknowledgements
• SECTION A - THE BASICS
• SECTION B - INDIVIDUAL SYSTEMS
• SECTION C - SPECIAL SITUATIONS
• Further reading
• Index