Our patient has coronary artery disease with angina pectoris and angina pectoris is a diagnosis made by the history. The typical character of the pain, burning, tightness, pressure, the typical location or, better, locations: jaw, shoulder, back, arms – radiation into those areas. The precipitating factors, such as exertion with increased cardiac work, such as emotional upset with outpouring of catecholamines and also increased cardiac work. This is a diagnosis made based on the history. But the bedside examination can be supportive and even helpful. In our patient, we found hypertension. Immediately we recognize that as a risk factor, as something that must be aggressively treated, and it is the typical background upon which coronary artery disease occlusion is built.
In our patient, at the apex, not [sounds]. That fourth heart sound, telling us that the ventricle, because of a background of hypertension, because of the ischemia to the left ventricular myocardium, that ventricle is less compliant, more stiff, and so when the atrium contracts generating blood into the left ventricle, that ventricle decelerates the blood more and, because of that, you hear this at the bedside as [sounds], and you can feel it at the bedside as well.
There are also several findings that were not present in our patient that you may occasionally find, that may also support your diagnosis of coronary artery disease associated with angina pectoris. You may feel an ischemic area of myocardium in this ectopic area, between the apex and the left sternal edge, due to bulging out of that myocardium during systole. You may, on auscultation, hear paradoxic splitting of the second heart sound at the upper left sternal edge, not on inspiration [sounds], but on expiration [sounds], because the aortic second sound is delayed due to such things as left bundle branch block or dysfunction of the left ventricle due to ischemia. You may at the apex not just hear a fourth sound, not filling sounds, but a murmur. The murmur of mitral regurgitation “lub-shtub,” “lub-shtub,” or if a fourth sound is present, “b’lub-shtub,” and that due to papillary muscle dysfunction.
The elegant closure of the mitral valve is disrupted by the ischemia to those muscles and, therefore, you get that subtle murmur of mitral regurgitation at the apex.
Again, it is the history that is paramount, and one can take a wonderful history by taking their patient through their daily activities, their exercise program, running at the airport with their luggage, bringing in the groceries; upset that occurs in an argument with a loved one or with someone at work. Then you will get that history of angina pectoris and you will also do something else that is very important, you will get to know your patient very well, and that fulfills the concept that sir William Osler stated so elegantly, that “you not only have to know what kind of disease a patient has, you also have to know what kind of patient the disease has.” And when we know that, we can even more wonderfully fulfill our obligations to our patients and even better care for them.
Summary discussion
The summary of our patient's history and physical examination includes the following key features: He was referred for a ple-employment check-up and initially stated he was in "good health." A careful history revealed symptoms completely consistent with angina pectoris. He also has multiple risk factors for coronary artery disease. His physical examination revealed a blood pressure of 150/100 mmHg and a fourth heart sound at the apex. It also excluded noncoronary artery disease etiologies of angina pectoris, such as left ventricular outflow tract obstruction.
The next step in his evaluation is to obtain a resting electrocardiogram.