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Tufts OpenCourseware
Author: Kanchan Ganda, M.D.
Color Key
Important key words or phrases.
Important concepts or main ideas.

1. The Chest

1.1. Chest pain

Although frequently thought to be due to heart disease; chest pain commonly originates from other structures, too.

1.1.1. Frequent causes of chest pain are:

Angina pectoris
Classic angina pectoris is brought on by exertion; it often follows a temporary increase in the myocardial oxygen demand, following exertion. The coronary arteries, usually narrowed secondary to coronary arteriosclerosis, are unable to supply the extra demand of blood flow. This causes temporary myocardial ischemia. The pain lasts for less than 5 to 10 minutes. The pain is alleviated by rest, because rest decreases the myocardial oxygen demand.
Myocardial infarction (MI)
is caused by an actual obstruction of the coronary arteries. When the myocardial ischemia is prolonged, it results in irreversible muscle damage or necrosis. The pain lasts for more than 5 or 10 minutes, and is not relieved by rest. Hospitalization is the norm for a successful outcome.
occurs because of irritation following fluid collection in the pericardial sac and is often seen in children suffering from rheumatic fever.
Pleural pain
is the irritation of the parietal pleura from acute pleurisy, pneumonia or tumor.
Reflux esophagitis
when gastric juices enter the esophagus, irritation of the esophageal mucosa results in inflammation and pain.
Hiatus Hernia
is when the stomach glides into the thoracic cavity through a very patulent diaphragmatic opening, when the patient lies down.
This is the most common cause of chest pain in children. Inflammation of the chest wall cartilages (costochondritis) is a frequent organic cause.

1.2. Palpitations

The patient becomes aware of his heartbeat. He may refer to it as skipping, pounding of the heart, racing or sudden stopping of the heart. Palpitations may be due to an increase or decrease in heart rate (tachycardia or bradycardia, respectively); an irregular heartbeat (arrythmia); or from increased force of cardiac contraction.

A rapid regular beating of sudden onset and cessation is is referred to as paroxysmal tachycardia. (The pulse rate is less than 120/minute during paroxysmal tachycardia.)

1.3. Dyspnea

Dyspnea is a "shortness of breath" experienced by the patient. It is nonpainful, but the patient is aware of his breathing. Dyspnea frequently is associated with anxiety, but can also be due to cardiac or pulmonary causes. Episodic breathing that occurs at rest and following exercise is suggestive of anxiety with hyperventilation. Deep sighs are frequently seen.

1.4. Orthopnea

Orthopnea is a dyspnea that occurs when the patient is lying down and is relieved when the patient sits up. The patient frequently states "using many pillows" to sleep. Orthopnea can occur due to obstructive lung disease, mitral stenosis, left ventricular failure or CHF.

1.5. Paroxysmal nocturnal dyspnea

Paroxysmal nocturnal dyspnea involves sudden episodes of dyspnea and orthopnea that wake the patient up from deep sleep. This makes the patient sit up and walk toward a window for fresh air. Frequently the attack subsides abruptly, but recurrence is common. Often associated with mitral stenosis or left ventricular failure.

1.6. Wheezing

Whistling respiratory sounds that may be heard by the patient or others. It is suggestive of partial airway obstruction, e.g., asthma.

1.7. Cough

Inflammation of the respiratory mucosa frequently causes coughing. Determine if the cough is dry or wet (i.e., causing a sputum or phlegm).

1.8. Hemoptysis

Hemoptysis refers to "spitting up" of blood. It may be a blood-streaked sputum or pure blood. If it is associated with coughing, the bleeding may have originated from the pharynx or mouth. If the patient vomited it rather than coughed it up, it probably originated from the gastrointestinal tract (hematemasis).

Blood originating from the stomach is darker than the blood from the respiratory tract.

1.9. Edema

Edema is an accumulation of excessive fluid in the interstitial spaces resulting in swelling. Frequently the patient will indicate a sudden weight gain if the edema is massive. Edema in the feet and legs is referred to as dependent edema. It may be cardiac in origin or due to local causes.

Think of edema if the patient complains of puffy eyelids and rings on fingers feeling too tight. Look for renal causes usually being responsible for the edema or hypoalbuminemia, if no cardiac or other cause established.

1.10. Syncope

If temporary loss of consciousness lasts for more than a few minutes in any patient, other causes to be considered are low carbon dioxide blood levels (hypocapnia) due to hyperventilation brought on by fear; low blood sugar levels (hypoglycemia); or hysteria. Hyperventilation syndrome is associated with paresthesias in the hands and around the mouth resulting in carpopedal spasms.

2. The Ears

  • Tinnitis is the perception of sound that has no external stimulus. Frequently heard as a ringing but may also be perceived as a rushing or roaring noise. Patient may hear it in one or both ears. If tinnitus is associated with hearing loss and vertigo, it is most likely due to Meniere's disease. The attacks then are frequently associated with nausea and vomiting. Meniere's disease is a result of generalized dilation of the membranous labyrinth (the inner ear).
  • Vertigo is a form of unsteadiness where the patient has a feeling of being pulled to the ground or off to one side during dizziness.
  • Discharge from the ear may be soft wax; debris from external ear canal inflammation; or a discharge through a perforated eardrum following acute or chronic middle ear inflammation.
  • The patient may experience pain within the ear or in the eardrum. The pain may be related to external or middle ear inflammation or infection. It can also be referred pain from structures in the neck, mouth or throat.
  • If there is an external ear inflammation, pulling on the pinna (ear tug) causes pain. This is a diagnostic sign for external ear infection.
  • If the middle ear is inflamed, pressing on the patient's mastoid bone (on the affected side) with your thumb will cause the patient to experience pain. This is a diagnostic test for middle ear problems.

3. Headache

  • Ask the patient if it is unilateral or bilateral.
  • Is it a steady or throbbing headache?
  • Is it associated with nausea and vomiting?
  • Determine if there is a chronological pattern to the headaches.
  • Is it a new and acute pattern or one that is chronic and recurring?
  • Is there any family history of similar episodes?
  • Migraine headaches are the commonly occurring recurrent headaches. They are frequently associated with nausea and vomiting.
  • Changing or progressively severe headaches may frequently be associated with organic causes like brain tumors.
  • If the patient states that coughing, sneezing or bending affects the headache, think of acute sinusitis as a frequent cause, brain tumor as a rare cause.

4. Fatigue

Fatigue is a symptom where the patient experiences a loss of stamina. It refers to a loss of energy, such that the patient is unable to accomplish regular activities. It is frequently associated with moderate to severe anemia; nutritional deficiencies; infections like the flu, mononucleosis, hepatitis, tuberculosis; diabetes, hypothyroidism, decreased adrenal functioning; chronic heart and lung diseases; rheumatoid arthritis; systemic lupus erythematosis (SLE).

5. Weight Gain

Rapid weight gain over a short period of time is frequently associated with fluid retention. Weight gain is commonly seen with hypothyroidism, type II diabetes, and depression.

6. Weight Loss

May occur because of anorexia (loss of appetite); vomiting, diarrhea, dysphagia (difficulty swallowing), malabsorption in the gut due to infections, broad spectrum antibiotics, or malabsorption syndromes; increased metabolic requirements due to hyperthyroidism, diabetes mellitus or Addison's disease (adrenal insufficiency); malignancies; anorexia nervosa or bulimia; chronic cardiac or pulmonary diseases, or depression (weight gain is more common with depression).

If patient indicates history of weight loss associated with excessive appetite, think of diabetes mellitus, malabsorption or hyperthyroidism. Also, try to rule out bulimia (binge eating).