Our patient has angina pectoris and that is an historical diagnosis. We shouldn't make this diagnosis based on a question: Do you have chest pain? Because we'll miss a lot of patients with angina pectoris if we do. Many patients will say: No, doctor, it is discomfort, distress, not pain, fullness. Many times they will say it is not in the chest, it's in the jaw, shoulders, back, arms, epigastrium, and so on. So we must ask the question in that manner. We must also characterize the symptom, not only by its character per se and its location or radiation, but what are the precipitating factors. Then we can define this important diagnosis of angina pectoris.
And what are the causes of angina pectoris? well, overwhelmingly, coronary artery obstructive disease. However, other diseases can also cause symptoms of angina pectoris and there are diseases that may mimic angina pectoris. Typically, outflow tract obstructive disease can cause angina pectoris whether it be muscular and below the valve or at the valve level with aortic stenosis. In addition, the mimics can include all the way from a patient with pulmonary hypertension that is severe, to patients with pericarditis and patients with mitral valve prolapse.
Now, the physical examination in a patient with coronary artery disease may not demonstrate many, many findings, but it still is important. Such simple things as looking at the patient, sometimes the overweight patient tells you right away about a risk factor. Sometimes you see xanthelasma on the eyelids and other findings from high lipid levels. And then you examine the patient in an orderly fashion and you may feel an ectopic impulse on the chest wall. That could be an ischemic bulge of myocardium that is not getting enough blood supply at that time. In addition, you may on auscultation hear changes in splitting of the second sound, such as paradoxic splitting occasionally and, certainly, at the apex you will commonly hear a fourth heart sound [sounds] with light pressure on the bell and, sometimes, the murmur of papillary muscle dysfunction in systole.
So, while the physical examination may not be the primary way to diagnose this problem or support the diagnosis, there is much important information on the physical examination as well.
General appearance
The first step in the physical examination is an evaluation of the patient's general appearance.
Our patient is a well developed, slightly overweight man who is in no acute distress. He shows no external findings on examination that reflect hyperlipidemia.
General appearance - hyperlipidemia
Hyperlipidemia is a major risk factor for coronary artery disease and may be detected when assessing the patient's general appearance. In addition to xanthelasma, that usually involves the upper eyelids, xanthomas may also be present. These nodular fat deposits are especially seen over tendinous areas.
Corneal arcus may also be a clue to hyperlipidemia, although it may occur in adults with normal lipid levels.