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TEMPO IN THE DIAGNOSIS OF SUDDEN ANTERIOR CHEST PAIN
OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Most of the books mention dissection of the aorta, pneumothorax and massive pulmonary embolism as differential diagnosis of pain of myocardial infarction. In this issue, I have also written down the value of ‘tempo’ of complaints in the differential diagnosis of fever and sudden headache.
I am writing this article to stress the point that in all the differential diagnoses mentioned above, the tempo of the illness is such that the appearance of anterior chest pain is ‘sudden’. The aortic dissection is then suspected by the presence of a murmur of aortic incompetence, unequal pulse at the wrist and the presence of severe hypertension. Pneumothorax will produce marked diminished air entry on auscultation and a hyper-resonant note on percussion. Massive pulmonary embolism will also produce marked diminished air entry but a ‘dull’ note on percussion or no physical signs in the chest but only presence of severe tachycardia.
All the above three conditions are less common in the population than myocardial infarction.
The point to be noted is, that in a middle aged or elderly person, who is possibly a diabetic or hypertensive, when the attack of myocardial infarction occurs, the tempo of the appearance of anterior chest pain is slow and often it takes a few minutes to 1/2-1 hour for the chest pain to build up and the patient to really complain of it.
Thus it will be noticed that the patients having the three illnesses mentioned earlier are immediately taken to the hospital or the doctor is urgently called for. While in myocardial infarction, the doctor is often called after 1 or 2 hours or even early in the morning, when the patient really had pain, which started in the middle of the night.
Thus, while history taking, the tempo of the symptoms of acute anterior chest pain can lead to an accurate diagnosis.
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