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Association~
Fighting Heart Disease
and Stroke
Part 1
Part 2
Inspection and Palpation of
Venous and Arterial Pulses
Michael H. Crawford, MD
Part 3
Examination of the Precordium:
Inspection and Palpation
Robert C. Schlant, MD, and J. Willis Hurst, MD
Part 4
Auscultation of the Heart
James A. Shaver, MD, James J. Leonard, MD,
and Donald F. Leon, MD
Part 5
The Electrocardiogram
Masood Akhtar, MD
Rheumatic Fever
27
29 Conclusion
31 Suggested Reading
The history is the foundation of the clinical diagnosis. The ability and
desire to obtain accurate, unbiased information is a major distinguishing
characteristic of every fine diagnostician. Although standardized
questionnaires, computers, and interviews conducted by paramedical
personnel have become increasingly useful in obtaining information, the
physician must still assume the major responsibility for ensuring that the
information is as complete and accurate as possible.
Despite the obvious necessity of obtaining accurate historical information
and relating that data to the physical examination, the clinical history,
unfortunately, may be neglected or slighted in favor of a glittering physical
finding or a multitude of laboratory tests. A brilliant biochemical diagnosis
may be the simple conclusion of a skilled medical interview.
In addition to accumulating essential historical information, the clinical
interview is the beginning of the patient-physician relationship, an
interaction in which the patient evaluates the physicians patience,
thoroughness, skill, and interest, and the physician seeks subtle clues
from the patients appearance, voice, expression, mannerisms, position in
bed, and breathing pattern. As James Herrick, an early 20th century
American cardiologist of great distinction, remarked, "The doctor may also
learn more about the illness from the way the patient tells the story than
from the story itself."*
This publication provides a basic approach to obtaining clinical history
related to the cardiovascular system. Common symptoms of cardiovascular
disease are also analyzed. A detailed discussion of the interrelations
among symptoms, physical signs, and pathophysiology may be found
among the titles listed under "Suggested Reading."
*Herrick J: Memories of Eight Years. Chicago, University of Chicago Press, 1949, chap
VIII, p 147
The patient may naturally hesitate to trust a stranger with intimate details
of an illness or personal frailties, a reluctance that may be heightened by
differences in age, gender, race, language, or socioeconomic background
between the patient and the physician. Fear and anxiety may lead to
subconscious repression of important information, inability to describe
certain symptoms accurately, faulty memory, or deliberate concealment of
facts such as drinking, poor compliance with medication schedules, and
intense emotional or sexual problems. The physician must try to foster a
relationship of trust by using communication skills. These techniques
require patience and insight and are important in the therapeutic content
of the medical history.
Once the basic symptoms have been identified, each must be teased
apart and examined from all angles. This is accomplished by exploring the
seven basic properties that differentiate a symptom of one disease from a
symptom of another. These basic properties are:
Bodily location. The area of origin of the symptom and the area of
radiation should be defined as precisely as possible.
Quality. The flavor imparted by the symptom may be described as
"sharp," "crampy," or "tingling." Inability to describe the quality may also
be informative.
Quantity. A symptoms quantity includes its severity, the number of
times experienced, and its duration.
Chronology. The chronology of a symptom implies its onset (as
precisely as possible) and sequential development until the present.
Setting. The setting of the symptom includes the time of day or night, if
the patient was active or resting, eating or fasting, emotionally upset or
relaxed, and at home or at work.
Aggravating or alleviating factors. The symptom should be further
clarified by asking what the patient did to gain relief, if a change in
position was sought, and what the effects of movement, respiration,
medication, etc. were.
Associated symptoms. Many diseases are manifested as a
constellation of associated symptoms that support a diagnosis when linked
together. The patient should be asked to describe other sensations
occurring before, during, or after the major symptom.
Historical Evidence
Have you ever had an illness or a problem related to your heart or
blood vessels?
Have you ever been told that you have or have had:
an enlarged heart?
a heart murmur?
a rheumatic heart?
a heart attack?
heart congestion or heart failure?
pericarditis?
a blood clot in the lung?
poor c, irculation?
stroke?
inflamed veins?
Have you ever:
been rejected by the armed services?
failed an insurance exam?
had a high rating on an insurance exam?
had an abnormal electrocardiogram or exercise stress test?
Have you ever taken:
digitalis?
water pills or diuretics?
pills to lower your blood pressure or cholesterol?
nitroglycerin pills under your tongue?
blood thinner?
heart medicines?
The following list of etiologies of heart disease is taken from the New
York Heart Associations Nomenclature and Criteria for Diagnosis of
Diseases of the Heart and Great Vessels.
Symptoms
Do you experience:
chest discomfort or pain?
shortness of breath during moderate exertion?
shortness of breath when recumbent?
swelling of your ankles?
dizzy spells?
fainting spells?
palpitations, skipped heartbeats, or a racing heart?
significant unexplained fatigue?
coughing at night?
coughing up blood?
cramps or pain in your calves, thighs, or hips while walking that is
relieved by rest?
Do you:
have to elevate your head with more than one pillow to breathe
comfortably at night?
have to arise several times during the night to urinate?
have tender or swollen calves?
have varicose veins?
These questions should effectively screen for the presence of heart
disease that is producing physiologic impairment. When chest pains and
palpitations are excluded, the symptoms are traceable to secondary effects
of heart disease on other organs, particularly the lung, brain, kidney, and
blood vessels. If the patient answers any question affirmatively, the
symptom should be explored in more detail, using the approach outlined
in the previous chapter.
Etiology
The clinician should try to establish an etiology by asking questions
directed to known causes of cardiovascular disease. The scope and
number of questions are tailored to the patient, based on symptoms, prior
illnesses, physical findings, and other information gathered.
Acromegaly
Alcoholism
Amyloidosis
Anemia
Ankylosing spondylitis
Atherosclerosis
Carcinoid tumor (argentaffinoma)
Congenital anomaly
Friedreichs ataxia
Glycogen storage disease
Hemochromatosis
Hypersensitivity reaction
Hypertension
Hyperthyroidism
Hypothyroidism
Infection
Marfans syndrome
Mucopolysaccharidosis
Neoplasm
Obesity
Polyarteritis nodosa
Progressive muscular dystrophy
Progressive systemic sclerosis
(scleroderma)
Pulmonary disease (cor pulmonale)
Reiters syndrome
Rheumatic arthritis
Rheumatic fever
Sarcoidosis
Syphilis
Systemic arteriovenous fistula
Systemic lupus erythematosus
Toxic agent
Trauma
Unknown
Uremia
Previous Therapy
This information provides the foundation for further therapy. It is particularly important to ascertain if the patient understood and followed the
prescribed diet and medications. The patient is often described as failing
to respond to therapy when in reality he or she is not taking medications
correctly nor adhering to prescribed diets. The patient may be confused
about the use of different medications or may not buy medications
regularly because they are too expensive. These problems can often be
resolved by asking the patient to bring his or her medicines to the office
for review.
The patient should be asked if the condition improved after starting a
medication or after cardiovascular surgery. Careful analysis of daily
activities, onset of symptoms, and the medication schedule may provide
essential information for future therapy. The patient should also be
questioned about his or her understanding of the illness so that
appropriate education can be initiated.
In planning a therapeutic program, the physician must also consider the
patients age, interests, other illnesses and limitations, financial needs, home
environment, and willingness to participate and return for follow-up care.
Common Symptoms
of Cardiovascular Disease
Chest Pain
Analyzing the many causes of chest pain to arrive at a correct etiology
can vex even the most astute clinician. Although there are numerous
causes of chest pain, the most important are angina pectoris, myocardial
infarction, pericarditis, pulmonary embolus, dissection of the aorta, chest
wall distress, and the pain of gastrointestinal disorders such as hiatal
hernia, esophageal disease or spasm, cholecystitis, pancreatitis, and
peptic ulcer distress.
The features of angina pectoris are described below in detail by using
the seven basic properties that separate angina pectoris from other
causes of chest pain. The distinguishing features of other causes of
chest pain are also discussed.
Angina Pectoris
In 1772, William Heberden described the clinical disorder he called
angina pectoris:
But there is a disorder of the breast marked with strong and
peculiar symptoms, considerable for the kind of danger belonging
to it, and not extremely rare, which deserves to be mentioned
more at length. The seat of it, and sense of strangling, and
anxiety with which it is attended, may make it not improperly be
called angina pectoris.
They who are afflicted with it, are seized while they are walking
(more especially if it be uphill, and soon after eating) with a
painful and most disagreeable sensation in the breast, which
seems as if it would extinguish life, if it were to increase or to
continue; but the moment they stand still, all this uneasiness
vanishes.*
11
Myocardial Infarction
The pain of myocardial infarction is usually, though not always, more
intense than angina pectoris and often exceeds 30 minutes in duration. It
often has a different quality, described as heavy, vise-like, crushing,
expanding, or squeezing. The patient may not be able to describe the
pain other than to say it was severe or intolerable. Radiation of pain from
the chest to the shoulders, neck, or arms is common. Associated
symptoms, including nausea, vomiting, sweating, dizziness, syncope,
marked weakness, palpitations, urge to defecate (chezonisus), fear of
death (angor animi), and dyspnea may be prominent.
Because many patients ascribe the discomfort of angina pectoris or
myocardial infarction to indigestion, the complaint of indigestion bears
particular scrutiny. Occasionally, a myocardial infarction is manifested as
acute abdominal pain, tenderness, rigidity, and vomiting. Rarely, the pain
is felt only in the back, neck, or shoulders.
The diagnosis of myocardial infarction often demands that the physician
maintain a high index of suspicion since the pain may be absent, insignificant, or attributed to other causes such as indigestion or gas. Other signs,
including unexplained heart failure, weakness, syncope, or arrhythmias
may be the major manifestation suggesting an acute myocardial infarction.
Patients who have had no recognized symptoms are sometimes found to
have had a myocardial infarction on routine ECG or at autopsy. The
incidence of silent infarction may be as high as 30%. Diagnosis of these
patients may confound even the most astute diagnostician.
Pericarditis
The pain of pericarditis is similar to myocardial infarction in its midchest
location and occasional radiation into the arm. On close questioning, the
patient with pericarditis will usually describe the pain as sharp, unlike the
pain of myocardial infarction. Accentuation of the pain with inspiration,
13
Pulmonary Emboius
A large pulmonary embolus that produces infarction of the lung is
usually easily diagnosed by the sudden onset of sharp, pleuritic chest
pain, dyspnea, hemoptysis, cyanosis, and tachycardia. More commonly,
pulmonary emboli do not result in pulmonary infarction and may provide a
diagnostic dilemma. The diagnosis of pulmonary emboli should be
considered if there is pleuritic pain, unexplained dyspnea (particularly if
the dyspnea is acute and episodic), atrial arrhythmias, cyanosis,
tachycardia, fever, or congestive heart failure.
The diagnosis is strongly supported by the occurrence of hemoptysis,
which is so infrequent, however, that its absence should not alter the diagnosis. Since pulmonary emboli usually occur in the setting of venous injury,
venous stasis, or alteration of blood coagulation, questions should be directed
to precipitating causes. The following information should be obtained:
Prior history of pulmonary emboli
Presence of leg or calf tenderness
History of heart, lung, or blood disease
Recent surgery (particularly hip surgery), pregnancy, trauma, bed rest, or
long car trip
Use of oral contraceptives
Use of constricting girdle or garter
Occupation (prolonged standing)
Presence of varicose veins or previous vein stripping
By realizing that pulmonary emboli occur in certain settings, particularly
in hospitalized patients, and that their clinical presentation is rarely classic,
the clinician may be able to make the diagnosis.
14
Aortic Disease
A dissection of the aorta is usually announced by sudden, severe,
midline pain often described as tearing or ripping. The pain may radiate
from front to back or down the midline into the abdomen or lower back.
The severity of the pain classically peaks at the onset. Symptoms of
vascular occlusion elsewhere, including myocardial infarction, may follow.
On occasion, this pain cannot be separated from other causes of chest
pain and may even be absent. The association of chest pain with a stroke,
occluded vessel to an extremity, or a new murmur of aortic regurgitation is
highly suggestive of aortic dissection.
An aneurysm of the aorta is usually silent until it expands or ruptures.
When the enlarging aneurysm impinges on the inner surface of the chest
wall, the patient may suffer from a boring, throbbing, or steady pain that is
localized in one area and prolonged or continuous.
Gastrointestinal Disease
Gastrointestinal disease, including esophagitis, esophageal spasm,
hiatal hernia, gastric or duodenal ulcer, erosive gastritis, dyspepsia,
cholecystitis, biliary dyskinesia, and pancreatitis may occasionally appear
as chest pain simulating ischemic heart disease. The most suggestive
clues to gastrointestinal disease are heartburn relieved by antacids,
dysphagia, and painful swallowing (odynophagia). Esophageal disease,
especially esophageal spasm, is particularly difficult to distinguish from
angina pectoris because both cause squeezing or pressure up and down
the midchest and radiation of pain to the neck, jaw, and arms, which is
quickly relieved by sublingual nitroglycerin. Esophageal disease is
suggested when the pain is related to eating, bending over, or
recumbency. Dysphagia is sometimes present. Although biliary disease,
gastric or duodenal ulcer, and pancreatitis can cause chest pain, close
questioning usually reveals that the pain begins in the abdomen and
radiates to the chest.
attack and diverts the physicians attention to the heart and away from the
chest wall. Careful questioning of the patient and a thorough examination
of the anterior and posterior chest is essential to make the diagnosis.
Shortness of Breath
Dyspnea implies difficulty in breathing and is a symptom common to
many diseases. The patient may describe this discomfort as shortness of
breath, inability to take a deep breath, smothering, cutting off of the wind,
asthma, or wheezing. It may be difficult to separate dyspnea due to
cardiac disease from other causes. This may vary from day to day,
depending on many factors; patients often say that they have "good days
and bad days." With advanced heart failure, shortness of breath is present
at rest or in any minimal activity.
Wheezing. In some patients, wheezing is a striking expression of pulmonary edema (cardiac asthma). Other causes of wheezing must be excluded.
16
Hyperventilation. Dyspnea related to anxiety and attendant hyperventilation is very common and may provide a thorny differential diagnosis,
particularly because hyperventilation often causes chest discomfort
simulating angina. Patients with breathlessness due to hyperventilation
often describe their symptoms as "The air doesnt go all the way down..."
or "1 cant get a full breath." The patient should be carefully observed for
signs of sighing, swallowing of air, and anxiety, and should be asked about
other symptoms of hyperventilation such as tingling or numbness in the
hands ("falling asleep") or around the mouth, dryness of the mouth, and
dizziness. When anxiety is associated with organic heart or lung disease,
determining the major contributing cause of the dyspnea may be perplexing.
18
19
2O
21
Palpitations
Irregularities of the heartbeat or tachyarrhythmias may be silent or experienced by the patient as palpitations, skipping, heart flutter, jumping in the
chest, or a runaway heart. Ambulatory monitoring studies have shown that
these sensations are often due solely to a heightened awareness of the
normal heartbeat, particularly when the patient is lying still in bed or is
emotionally upset, or for no apparent reason. An arrhythmia may also
create a secondary effect such as dizziness, syncope, seizure, blurred
vision, chest discomfort, or dyspnea.
Isolated premature atrial or ventricular beats are common and unnoticed
by most people. However, some people are very aware of the irregularity or
the forceful postextrasystolic contraction and may seek advice and
reassurance.
Atrial tachycardia (AV nodal reentry) is often abrupt in onset and
termination and quite regular in rhythm as contrasted with atrial fibrillation,
which is generally irregular and less striking in the suddenness of its
initiation and termination. When atrial fibrillation is rapid and irregular, the
patient may describe the feeling as a "thumping or fluttering in the chest."
The symptoms caused by these arrhythmias may overlap, or the patient
may not recognize these features.
Ventricular tachycardia may be easily tolerated even if the heart is very
diseased. If the patient has significant coronary or myocardial disease, the
common manifestations are dizziness or syncope, chest pain, and
dyspnea. The patient may or may not appreciate the presence of the rapid
heartbeat. Sometimes the patient comes to the emergency room in shock
or severe heart failure and is discovered to have ventricular tachycardia.
Patients who take digitalis or have permanent cardiac pacemakers or a
large stroke volume (as occurs with aortic regurgitation) are sometimes
frightened by the forcefulness of their heartbeat.
Diagnosis may be difficult because of the diversity of presentation and
the frequent disappearance of arrhythmia by the time the patient sees a
physician. The following questions are often helpful in searching for
occurrence of an arrhythmia:
Recent Attack
When did it start?
Where were you and what were you doing?
Did it start or end abruptly or gradually?
How long did it last?
Were you able to count the pulse rate?
Was the rhythm regular or irregular?
22
23
Can you mimic the rate and rhythm by patting your fingers on top of the
other hand?
Were there associated symptoms such as:
chest discomfort?
weakness?
dizziness?
fainting?
visual blurring?
sweating?
Do you take:
diet pills?
amphetamines?
stimulant pills?
Prior Attacks
Have you had similar attacks in the past? (If so, obtain preceding information.)
If so, how frequently do they occur? Have you been examined or given an
ECG during an attack?
Have you found any positions, maneuvers, or medications that have halted
or prevented attacks?
Fatigue
Edema
Retention of salt and water in patients with cardiac disease and heart
failure may result in soft tissue swelling in the feet and around the ankles.
This formation may be described by the patient as swelling of the feet or
puffiness around the ankles. Since gravity promotes fluid extravasation
from intravascular to extravascular spaces, the edema becomes worse as
the day progresses and generally disappears or improves with nighttime
recumbency. The return of fluid to the vascular system at night produces
nighttime diuresis, and patients complain that they frequently arise to
urinate. As heart failure progresses, fluid accumulation may involve other
tissues, particularly the eyelids and sacral areas.
Fluid may collect in the abdomen with advanced right ventricular failure.
As this ascitic fluid increases, the patient may be aware of abdominal distention and bloating. Right upper quadrant pain and tenderness may also
occur as a result of hepatic congestion from high central venous pressure.
Cardiac disease is only one of several possible explanations for fluid
retention. Often several factors contribute to formation of edema.
25
Intermittent Claudication
Rheumatic Fever
Cyanosis
Although cyanosis is a physical finding and not a symptom, the patient
or a family member may notice that the skin is blue, dark, or dusky. This
information is extremely important in the infant, as it suggests the
presence of congenital heart disease with right-to-left shunting of the
underoxygenated blood into the arterial circulation. Cyanosis may be
apparent only when the child is crying, feeding, or exercising vigorously.
Additional information is gained by asking if cyanosis was present at birth
or if it appeared later in life.
Cyanosis in the adult has less specific implications and may be due to
lung disease, pulmonary emboli, congenital heart disease, or abnormal
hemoglobins. Cyanosis with dyspnea should always suggest the presence
of a large occluding pulmonary embolus. Cyanosis is not a sign of
congestive heart failure unless there is severe impairment of peripheral
capillary blood flow.
26
27
Major Manifestations
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor Manifestations
Clinical
Previous rheumatic fever or rheumatic heart disease
Arthralgia
Fever
Conclusion
Laboratory
Acute phase reactants
Erythrocyte sedimentation rate
C-reactive protein, leukocytosis
Prolonged PR interval
28
29
Suggested Reading
Beckman HB, Frankel RM: The effect of physician behavior on the collection of data. Ann
Intern Med 1984;101:692-696
Duffy DL, Hamerman D, Cohen MA: Communication skills of house officers. Ann Intern
Med 1980;93:354-357
Enelow A J, Swisher SN (eds): Interviewing and Patient Care, ed 2. New York/Oxford,
Oxford University Press, 1979
Fletcher C: Listening and talking to patients. I: The problem. Br Med J 1980;281:845-847
Fletcher C: Listening and talking to patients. I1: The clinical interview. Br Med J
1980;281:931-933
Fletcher C: Listening and talking to patients. II1: The exposition. Br Med J
1980;281:994-996
Fletcher C: Listening and talking to patients. IV: Some special problems. Br Med J
1980 ;281:1056 - 1058
Hurst JW: The Heart, ed 7. New York, McGraw-Hill Book Co, 1990
Morgan WL Jr, Engel GL (eds): The Clinical Approach to the Patient. Philadelphia, WB
Saunders Co, 1969, pp 1-79
Platt FW, McMath JC: Clinical hypocompetence: The interview. Ann Intern Med
1979;91:898 - 902
New York Heart Association Criteria Committee: Nomenclature and Criteria for Diagnosis of
Diseases of the Heart and Great Vessels, ed 8. Boston, Little, Brown & Co, 1979
Tumulty PA: What is a clinician and what does he do? N EnglJ Med 1970;283:20-24
Walker HK, Hall WD, Hurst JW (eds): Clinical Methods, ed 3. Boston, Butterworth, 1990
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