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Department of Internal
Medicine
UNTHSC
A 56 year old male presents for
evaluation of heaviness in chest
while mowing his lawn. There is
no cough, but some dyspnea.
Symptoms abate after a cold
drink and a few minutes break.
He feels worn out afterwards
for several hours.
He has no history of chronic
illness, and these symptoms
are recent. He takes no
medication. He smokes an
occasional cigarette. He has
not had a physical for at least
10 years
On examination, his BP is
148/96 with a pulse of 90. He
has a soft bruit over the right
carotid. Cardiac ascultation
reveals an S4 at the apex.
Lungs are clear. Abdomen is
benign, as is his peripheral
examination.
Recognizing Clinical Clues to the
Diagnosis of Angina
Clues in the History
ClassicLevine sign correlates well
in males
Pressure or squeezing sensation
more correlative than pain
Radiation pattern to left arm,
shoulder, jaw, neck or hand
Associated diaphoresis and nausea
are ominous markers
Clues in the History
Significantischemia often results in
prolonged periods of fatigue
Ischemic pain rarely lasts longer than
thirty minutes
Ischemia presents as painless
dyspnea in 25% of cases
Clues in the History
Pain with activity, or pain with
activity and at rest correlates with
ischemia better than pain only at rest
Pattern of discomfort in women
highly variable
Claudication separate from chest
discomfort
Risk Stratification by History
Major risks
Diabetes mellitus
Family History of premature
atherosclerosis in first degree relative
Lipid disorder (high LDL, or low HDL)
Smoking
Hypertension
Clues in the Physical
Examination
Evidence of vascular disease
funduscopic exam- copper wiring or plaque
large artery bruits
pulse abnormalities