From a Western medical point of view, the first broad differentiation to be made in a patient with
chest pain is whether the pain originates from the lungs, heart or stomach/oesophagus.
The main causes are represented diagrammatically in Figure 13.3Figure 13.3.
Pleurisy
This is an inflammation of the pleura. Its diagnosis should be fairly obvious as it occurs only
during an acute febrile disease affecting the chest. The pain is worse below the nipple and is
definitely worse on inhalation and coughing. The patient's breathing is rapid and shallow. There
may be an unproductive cough. The temperature is raised.
The diagnosis of pleurisy can be confirmed with the help of a stethoscope. When this is placed
over the chest (both front and back should be checked) a typical friction "rub" can be heard at the
end of exhalation or inhalation. This is due to the rubbing together of the two pleural surfaces.
This friction rub can be differentiated from other lung sounds as it does not disappear after
coughing. It is therefore advisable, when an adventitious sound is heard, to ask the patient to
cough: the pleural rub will not disappear whilst the sounds generated by mucus in the bronchi
will.
Lung Embolism
This occurs when an embolus detaches from a thrombus and occludes (partially or totally) an
artery in the lung. The main predisposing factors for this to happen are:
(a) slow circulation from dilatation and inefficiency of the veins such as that which
occurs during pregnancy or in patients with varicose veins. It also affects people
who have been confined to bed for a long time. It is particularly likely to occur
within 10 days after surgery or childbirth(b) pulmonary congestion deriving from mitral stenosis or congestive cardiac failure
in the elderly(c) trauma(d) the contraceptive pill.The manifestations of lung embolism vary in severity according to whether a lung artery is
totally or partially occluded. If it is totally occluded there is a massive embolism and the patient
is seized by an extremely severe chest pain and looks under shock. There is intense
breathlessness, pallor, faintness, sweating and there may be collapse or even death. The blood
pressure falls to very low levels and the jugular venous pressure is raised. From the point of view
of Chinese medicine it corresponds to collapse of Yang and an acupuncturist would be extremely