6 The Medical Historyand Symptoms of Heart Disease

(1)

87

From: Essential Cardiology: Principles and Practice, 2nd Ed.

Edited by: C. Rosendorff © Humana Press Inc., Totowa, NJ

6 The Medical History

and Symptoms of Heart Disease

H. J. C. Swan, ^MD , ^P

^h

^D

^*

INTRODUCTION

The medical history and physical examination provide the most fundamental information regarding personal health and the need for specific medical care. It is the purpose of this chapter, first, to restate and underscore the objective of the taking of a medical history in general, and then to consider the nature of complaints that may be associated with cardiovascular disease in the adult patient. Specific symptom profiles and presentations are best discussed in association with specific clinical entities, including the chapters on ischemic heart disease, acute myocardial infarction, and congestive heart failure. Symptoms related to congenital malformations with associated cardiac lesions, including “failure to thrive,” cyanosis, and heart failure in the neonate will not be considered in this chapter. The principal symptoms are summarized in tables, followed by a short comment on general issues. The onset and severity of a principal complaint may dominate the initial history taking, and relief of distressing symptoms becomes a first priority. However, it is then essential to return to obtain a complete and comprehensive medical and cardiac history.

Because of the overall primacy of atherosclerosis (1,2) as a cause of vascular and heart disease, specific inquiries must be made to include a risk evaluation for atherosclerosis, not only for the coronary arteries but also for the aorta and its principal branches. (The factors currently deemed most important are listed in Table 1.) Gender offers no specific protection, as heart disease is the most frequent cause of death in women although later in life than men. Women are equally prone to congenital and rheumatic heart disease, arrythmias, and the less common diseases such as cardiac tumor.

The medical history gives the physician the ability to define the more likely diagnoses, and to achieve a level of confidence sufficient to allow logical action—additional testing, treatment, optimal management decisions, including reassurance, and lifestyle modification. Each concep- tual step must be a “what if ” and “if–then” form of clinical reasoning. However, more advanced testing strategies must follow, and not precede, a careful consideration of the initial history, the physical examination, electrocardiogram, chest X-ray, and basic blood and urine testing. A physician who claims to be “objective” with an intellectual, or strictly academic, approach may not meet a fundamental emotional need of the individual patient. In his epic “The Ballad of Reading Gaol” (3), Oscar Wilde wrote: “Something was dead in each of us, and what was dead was hope,”

that never-to-be-forgotten or ever-to-be-ignored yearning of each and every person. Many years ago, the famed surgeon, William James Mayo of Rochester, Minnesota, characterized his fellow doctors: “One meets with many men who have been fine students, and have stood high in their classes, who have had great knowledge of medicine but very little wisdom in its application. They have mastered the science and have failed in their understanding of the human being” (4).

*Jeremy Swan died before the publication of this edition. He was a giant of cardiology, and a gracious and generous friend.

(2)

THE HISTORY (5)

The fundamental objective of this encounter is to initiate a process of interaction and confidence-building between patient and physician. The purpose is to include the most likely possible causes of complaint, along with other aspects relevant to the patient’s well-being. History-taking is far more an art than a science (6). It is an exercise in unstructured probabilistics, and should be so regarded. In all this, the opportunity to establish a sense of trust and confidence between physician and patient is paramount. After all, it is the patient who has “hired” you, not the contrary.

As Claude Bennett put it, “the good doctor becomes a friend and resource for his patient in regard to family, suffering, aging and dying” (7). In a commentary, “Humility and the Practice of Medi- cine,” James Li suggests that the overconfident physician who believes that medical science and technology are sufficient subordinates the patient-physician relationship. Competency, concern, compassion, and caring are the hallmark of best medical practice, but there is a place for the honest

“I don’t know,” tactfully put (8).

Initial Presentation

The history-taking in a “first visit” patient is a vital part of the practice of medicine and of its subspecialties, including cardiology. Clearly, medical history-taking differs for an initial elective, a follow-up, a “consultation,” or the emergent presentation of a patient. In a “first visit” the physician will assess the general health of the patient and develop impressions as to educational and intellectual background and thus the accuracy and credibility of the patient’s “story.” The attitudinal, social, and emotional makeup of the patient is clarified by nonverbal as well as verbal communication. At the same time, the prudent patient will assess not only the physician’s professional com- petence but also his or her communicative ability to address the patient’s needs and concerns appro- priately. While personalities and attitudes differ widely among patients and physicians, every patient must feel that the physician is “on my side.”

Table 1 Atherosclerosis Risk Age and gender

Past cardiovascular events

Stable angina pectoris, unstable angina, acute myocardial infarction, revascularization procedures, prior testing for ischemia, previous emergency room visit for chest pain, positive family history of premature cardiovascular events (history of a major cardiovascular event in a first-degree relative, by age 50 yr for males and 55 yr for females)

Present symptoms and medications

Chest discomfort/pain requiring antianginal medications Blood pressure requiring antihypertensive medications Familial hyperlipidemia

Conventional metabolic and endocrinological factors

Blood lipids, elevated LDL-C, low HDL-C, elevated triglycerides Elevated blood glucose, and glucose intolerance

Thyroid status, menopausal status Body weight, obesity

Personal habits

Cigarette smoking—never, former, current, how many?

Dietary composition

Activity level—sedentary, ordinarily active, exercise program Alcohol usage—for how long, how much

Personality profile Socioeconomic status

Psychosocial, familial, and occupational stress and coping

(3)

The Complaint

A complaint is defined as “an expression of discontent, regret, pain, censure, resentment, or grief”

(9). Each of these elements enters into the complaint and thus into the analysis of symptoms.

However, the fundamental objective remains: to effect reductions or enhancements of the prob- ability or possibility of a specific organic or functional cause for the complaint. “The nature of man is best understood by the company he keeps.” So it is with the medical history. The commitment of appropriate time for an initial history is essential. The patient expects to be listened to, and his or her concerns respected and understood. A careful and complete history is the shortcut to appropriate additional testing and the defense against waste of resources. Specific complaints must be considered against the background and demography of the patient, if their significance is to be ana- lyzed effectively. The initial history for any patient must include and record with accuracy the elements of age, gender, racial origin, education, occupation, socioeconomic status, family status, and physical activities.

The noncardiovascular history must be incorporated since many complaints commonly associated with cardiovascular disease may be due to other disorders—for example, dyspnea in emphysema and bronchitis, or ankle edema in patients with renal insufficiency, obesity, or venous varicos- ities. A detailed inquiry into past and current medication must be made. All medications taken by the patient must be listed. From time to time patients referred for a “cardiology” consultation feel that medications for other noncardiovascular complaints may not be relevant and therefore these may go unreported. Likewise, the family history requires careful exploration, since, in the US, many patients are far removed from their place of origin. A spouse or other family member may provide unexpected information—for example, a history of prior premature heart disease or death in genetically related individuals. In regard to specifics of complaints in cardiovascular disease, consideration centered only on the chief complaint of the patient is likely to result in significant error.

Observation of nonverbal communication between spouses may be a useful guide to future compliance with recommended treatment. In all these matters, a physician’s behavior influences a patient’s response. Patients who suspect or are suspected of heart disease come with a sense of uncertainty or even fear. The simple open-ended questions, “Tell me how you feel” and “How can I help you?” are important, as they imply physician concern, invite the patient to express himself or herself in a personal way, and then allow the physician to inquire further concerning the complaint. While every effort must be made not to “lead the patient,” it is essential to understand the intrinsic limitations of the patient’s understanding of medical questions, necessitating specific direct inquiry. A good example is the heart failure patient who no longer complains of shortness of breath because his activity level has now been reduced to a degree appropriate to his residual ventricular function. It is a useful exercise to “live through a day” with the patient by a brief verbal “diary” of his or her activities and attitudes. A knowledge of the issues that disturb or please the patient assists in the overall assessment. It also provides information concerning physical activity. In patients with existing disabilities, the impact of emotional, social, and functional limitations in matters large and small have become the continued living experience of the patient. In many, prior testing for heart disease may have been done, including exercise stress testing, angiography, cardiovascular interven- tion procedures, and vascular scanning, including estimation of the state of the carotid and systemic arteries. Tests for the presence of coronary calcification are now available and increasingly common, and may be the precipitating reason for a patient visit. Each test should be documented with care and entered in the medical record. Whenever possible, original copies of such reports must be obtained.

Follow-Up, Emergent, and Consulting Visits

While the initial visit provides the bedrock of understanding, the circumstances of presentation determine the nature and purpose of the later medical history. Follow-up visits are usually structured to document responses to treatment, since in an effective practice, an accurate prior profile should exist and should be available for comparison. The physician time commitment of an initial

(4)

visit may not be required. A careful record of current medications and laboratory and other test results may be made by a specialty nurse and, when appropriate, reported to the patient. But such a visit is always worth a “How are you doing?” from the physician, with a specific inquiry as to changes in a principal complaint, a new event, new test results, or response to medication. Emergent visits assume the availability of at least a minimum of prior information; usually the issues at hand are specific. When patient survival is in question, the obtaining of full historical details will, of necessity, be deferred. In contrast, a formal consultation requires a clearly defined purpose—diagnosis, management, procedure, and reassurance. Here the interview establishes, in great detail and with precision, the nature and significance of complaints, and the relation of physical examination and other data relevant to an optimal strategy.

Questionnaires, Nurse Practitioners, and Physician Extenders

The history taking may be facilitated by a questionnaire, which is best sent to a patient several days before a first visit. A questionnaire raises important general issues in a patient’s mind and provides opportunity for unhurried thought and discussion with family members. Also, it promotes the careful completion of essential demographics, the inclusion of secondary complaints, and a considered review by the patient and spouse of family and past histories and medications. A trained physician assistant may review the responses and obtain clarification when necessary. The interview must be unhurried, with the patient receiving sufficient time for self-expression and for clarifica- tions of uncertainties in his or her own mind. Because accurate and specific information is required and patients may be unfamiliar with symptoms and their significance, direct inquiry is usually necessary. Patients feel (properly) unsatisfied if the duration of the initial consultation is such that many of their concerns go unassessed and unanswered. There may be important advantages if a spouse or family member is involved in an initial interview, or at least be present for the physician’s summation and recommendations. When physicians interview a patient, absent a spouse, symptoms and other important information may go unreported. On the other hand, the presence of a spouse may inhibit an open interview with some patients. Elements of family history may be denied or forgotten and the interspousal and personal dynamics, possibly relevant to future management and compliance, will become evident. Also, in elderly patients, a younger party may provide a more accurate reporting of specific complaints. This is even more essential for patients whose primary language is not that of the physician. While an interpreter may translate, the actual meaning of the words can be confused. An experienced physician assistant or nurse practitioner can inform a patient of the findings, but the conclusion of an initial interview is best addressed directly by the physician

—and always when conducted by consulting subspecialists. The needs of the poor and underserved pose a major challenge to providers, and require innovative approaches. The important and expand- ing role of nurse practitioners in primary care, follow-up, and extended caregiving is predicated on the confidence of the patient regarding a “team support” approach embedded in prompt physician participation.

The Medical Record

Clinical information and its meaning are subject to scrutiny regarding their accuracy, precision, variability, sensitivity, and specificity (11). In this respect the veracity of the medical record is paramount. To record is “to set down in writing of the like, as to the purpose of presenting evidence” (12). This definition implies that the facts be described accurately and be complete, inclu- sive, and, when proper, available to and understandable by persons of similar backgrounds to the originator of the record. Also, the record should be readily available when required for a specific purpose. Current medical records seldom fulfill these criteria, are usually incomplete, not easily available, frequently handwritten, and many times only partially legible. This is a particular problem with emergency room reports, which may be a critical part of the admission or call for an immediate cardiac consultation. In legal disputes, a physician may be required to read his or her notes into the court record to allow for reasonable interpretation by counsel or by other physicians. It

(5)

is essential that this serious deficiency of record completeness and legibility be corrected, as an accurate record is vital to the provision of both immediate and long-term medical care. Desktop and handheld automated devices now exist for the effective collection of diagnostic information of all sorts, including a detailed medical history. Thus reliable, computerized patient records have been successfully introduced into hospital-based and office-based services, and a variety of soft- ware packages are available. These provide a computerized and totally integrated record system, which includes notes, order entry, laboratory, and other data, and lists of medications. Some also include drug interactions, risk analyses, and clinical guidelines. There are also some excellent physician dictation systems. While these all offer great advantages with respect to legibility, accessibility, and integration, it should be recognized that some physicians believe that the computer is a greater obstruction to easy physician-patient interaction than are pen and paper. This is changing rapidly as the enormous benefits of computerized patient record systems become better known.

After the History

An effective history is followed by the inclusion of other factual observations, including the findings on physical examination, the standard 12-lead electrocardiogram, the chest X-ray, and basic laboratory data, including a blood lipid panel and blood glucose. Each of these contributes to the ongoing process of qualitative, unstructured probabilistics relative to a specific anatomic or functional diagnosis. Physicians must recognize the intrinsic reality of such a process, and apply scientific reasoning whenever possible. This will allow conclusions as to appropriate areas for further investigation, in order to improve or cast doubt on the direction of diagnostic inquiry. In particular, such an analytic approach usually allows a physician to exclude the least probable causes and to proceed logically to a correct diagnosis.

CARDIAC SYMPTOMS

The principal symptoms associated with cardiovascular disorders are listed in Table 2. Each will be considered briefly regarding relevant causation. Also, it is essential to distinguish between the far more frequent noncardiac and the far more serious cardiac causations. Symptoms associated with heart disease are frequently activity-related, as in angina pectoris and heart failure and certain dys- rhythmias. But a particular symptom, or its absence, may serve to favor certain possibilities over others.

Chest Pain or “Discomfort in the Chest”

The principal causes of chest pain are listed in Table 3. Table 4 lists the characteristics of chest pain that should be recorded. Chest pain is one of the most frequent symptoms leading to a visit to a physician or cardiologist. It is the most common, and possibly the most important, symptom associated with heart disease, yet it is neither highly sensitive nor specific for a specific diagnosis.

Chest pain may range from brief, transient, mild discomfort to continuous, excruciating pain. In general, the more severe the pain, the greater is the likelihood of important underlying pathology.

Table 2

Symptoms Associated With Cardiovascular Disease Pain (in the chest and elsewhere)

Dyspnea on effort, orthopnea, paroxysmal nocturnal dyspnea Fatigue on exertion, at rest

Embolic manifestations

Complaints related to systemic disorders with a possible cardiovascular cause or relationship

(6)

Table 3

Causes of “Discomfort in the Chest”

Chest Wall

Cervical/thoracic spine osteoarthritis Intervertebral disk disease

Intercostal neuritis Rib fracture Costochronditis Herpes zoster

Intrathoracic—Cardiovascular Vascular

Aortic dissection Pulmonary hypertension Myocardial

Stable angina pectoris Unstable angina

Prolonged myocardial ischemia Acute myocardial infarction Pericardial

Acute, subacute pericarditis Malignancy

Other

Mitral valve prolapse Hypertrophic cardiomyopathy Intrathoracic—Pulmonary

Acute pneumothorax Pleurisy and pleural effusion Pneumonia

Pulmonary embolism Referred from other organs

Gastroesophageal reflux

Esophagitis and esophageal spasm Peptic ulcer disease

Pancreatitis Gall bladder disease

Table 4

Characteristics of “Discomfort in the Chest”

Intensity: severity, continuous/discontinuous, easing/worsening

Quality: visceral, superficial, pressure, crushing, stabbing, burning, tearing Location: retrosternal, suprasternal, epigastric

Referral to: chest wall, back, right shoulder, right arm, both arms, jaw, occiput, head, epigastric, right, left subcostal, abdominal

Onset: sudden, gradual, precipitating cause (if any) Worsened by: activity, breathing, position

Associated with: anxiety, coughing, dyspnea, nausea, vomiting, diarrhea, sweating, pallor, cold extremities, abnormal heart rate

CARDIAC ISCHEMIA

Although many forms of heart disease are associated with discomfort in the chest, by far the most important is that due to coronary atherosclerosis. Ischemic pain is the sensation caused by an imbalance between available oxygen supply and the metabolic demand of working myocardium.

The afferent pathway is complex and the resulting symptoms also are complex and variable in regard to intensity, location, and radiation. Is the pain continuous or intermittent?

(7)

The “onset” characteristics may be defining. Transient substernal chest discomfort or discomfort on activity or climbing stairs, excitement, anxiety, postprandial, or cold, favor angina pectoris. Fever, tachycardia, or anemia may precipitate “new” angina or worsen existing angina. In general, the pain of angina pectoris recurs at a repeatable level of activity or emotional stress, rapidly regresses when the activity ceases, and is reproducible under comparable circumstances.

The duration of effort-related angina is usually short and self-limited, and described as “pressure,”

“constrictions,” “squeezing,” and “unlike anything I have ever experienced.” Severe unrelenting pain is suggestive of ongoing severe myocardial ischemia and acute myocardial infarction. Inter- mittent recurrent pain may be associated with stable or unstable angina pectoris. Other qualitative descriptors of angina pectoris include “new,” “accelerated,” “progressive,” “preinfarction,” and

“nocturnal.”

An “angina equivalent” refers to dyspnea as an alternative symptom that occurs under similar circumstances to common angina pectoris. Stable angina occurs predictably following a certain and constant level of exercise. “Unstable angina” includes angina of new onset (less than 1 mo), symptoms increasing in severity, frequency, and intensity, precipitated by less exercise load than before, or changing pattern of radiation, without enzymatic evidence of infarction. This entity is due to partial and transient thrombotic occlusion of a diseased vessel and may progress to a com- pleted infarction.

LOCATIONAND RADIATION

Ischemic chest pain is usually substernal with varying radiation patterns, the most common of which is into the left shoulder and the ulnar aspect of the left arm. Pain is usually perceived as pressing, constricting, and heavy, frequently associated with activity but not necessarily so.

Although classically centrally located pain characterizes ischemia, pain may be solely in the neck and jaw, left shoulder or left arm, and may not radiate. Atypical distribution patterns are not unusual and include the right chest alone and the epigastrium without radiation to the neck or arms. How- ever, in a high-risk individual, e.g., a male 60 yr of age or older, the presence of any chest pain raises a possibility of underlying coronary disease. Other causes of chest pain—the acute tearing of aortic dissection or aneurysm and pain associated with respiration as in acute pneumothorax, pleurisy, pneumonia, pericarditis, or pulmonary embolus—may be identified on the basis of their specific characteristics. The initial pain of aortic dissection may be described as “the worst possible,” and may be located in or radiate to the back. Pleuritic chest pain is worsened on inspiration or coughing. The severity and duration of pain are useful indicators, with rapid relief in angina pectoris; more prolonged, yet with relief in unstable angina; and persistent and perhaps increasing with acute infarction. The association of nausea, vomiting, sweating, and anxiety with chest pain is suggestive of evolving myocardial infarction. Angina at rest is usually caused by severe prolonged myocardial ischemia, may be spontaneous, and often occurs at night, waking the patient from sleep.

Chest pain associated with nausea, vomiting, palpitations, a feeling of weakness, and fear is common in acute infarction.

N^ONCARDIAC C^HEST P^AIN

Pain secondary to peptic ulcer, gall bladder disease, gastric reflux, and esophagitis, as well as spinal disease and costochondritis, is much more frequent than cardiac chest pain. In these conditions pain may be spontaneous, may be related to meals associated with recumbency (reflux), and may be relieved by antacids or by food itself. The pain and discomfort of esophageal spasm may be relieved by nitroglycerin. Chest pain associated with ingestion of food, swallowing, coughing, and position changes is less likely to be of cardiac origin. Musculoskeletal pain, if variable, differs in location and severity, and is worsened by respiration, other movements and localized pressure. Attention to simple demographics (age, gender, prior history) will usually, but not always, serve to clarify the complaint. Even though, for example, acute infarction is uncommon in younger women, the assumption “it could not be” has resulted in tragic outcomes. Ischemia should always be considered in older patients reporting new-onset chest pain. The key in differential diagnosis

(8)

is an awareness of such possibilities, but in many cases a diagnosis as to causation can be established with confidence based on history alone. Anxiety (which frequently is justified) can color the symptom presentation. Pain due to pneumothorax, pleurisy, pneumonia, or pulmonary embolism is worsened on inspiration, and patients will minimize the effort of breathing with unilateral chest splinting.

Pain of pulmonary origin, in general, does not radiate and is localized to one side or the other and is seldom substernal. The discomfort associated with other forms of heart diseases—mitral valve prolapse, pulmonary hypertension, and hypertrophic cardiomyopathy—is usually not sufficient to cause severe distress. Functional chest pain associated with fear of heart disease or due to an anxiety state is usually described as acute, sharp, and stabbing, and frequently located to the cardiac apex.

At times, it is associated with hyperventilation, but is not usually exercise-related. However, it may subside relatively rapidly.

Factors associated with relief of pain are all important. Relief with cessation of activity and nitroglycerin suggest angina pectoris. Worsening or an unchanged level of pain under those circumstances is consistent with unstable angina or myocardial infarction, or with aortic dissection.

Acute pericarditis may be relieved by leaning forward. In brief, any complaint that includes chest pain is deserving of careful interrogation and analysis.

Dyspnea

Dyspnea is defined as an uncomfortable awareness of the necessity of breathing. It is a common symptom in both cardiac and pulmonary disorders, as well as a reaction to anxiety. It is frequently associated with an increase in pulmonary venous pressure. The principal causes are listed in Table 5.

Dyspnea, in and of itself, is not abnormal, as this symptom is universal at several levels of exercise, including treadmill testing, and even trained athletes may experience it. However, an awareness of an abnormal need for breathing under conditions of mild or moderate exertion or at rest is significant. Acute-onset dyspnea is usually of pulmonary cause—for example, acute pneumothorax, pleurisy, pneumonia, or pulmonary embolus—but may also be a major, early feature of an exten- sive myocardial infarction, acute valve regurgitation, and pericarditis. The dyspnea of congestive heart failure is experienced at decreasing levels of external work, and finally, under resting conditions. Dyspnea may be associated with cardiac causes for chest pain. A prior history of smoking or other disorders, including recurrent chest infections, bronchitis and emphysema, congestive heart failure, and the associated presence of acute myocardial infarction serve to define the cause of this symptom. Again, relief of dyspnea should occur when the precipitating cause is removed or alle- viated. Several factors contributing to dyspnea include deconditioning and obesity, as well as fever, tachycardia, or anemia. Of interest, anxiety-induced hyperventilation is commonly misinter- preted as dyspnea.

Orthopnea indicates a severe level of dyspnea in which the patient is unable to lie flat and must sit in an upright position. Paroxysmal nocturnal dyspnea is usually associated with chronic heart failure. Beginning shortly after sleeping flat, it is relieved by attaining the upright position. The common mechanism is an increase in pulmonary venous pressure due to mitral valve disease or left ventricular dysfunction. Acute pulmonary edema is an expression of pulmonary venous hypertension with transudation of large quantities of fluid into the alveoli, precipitating severe coughing with expectoration of frothy fluid that may be blood-stained. “Functional” dyspnea often occurs at rest and is associated with apical stabbing or prolonged chest-wall pains.

Fatigue

This is a transient weariness during exertion, due to an imbalance between the metabolic demands of working skeletal muscle and the availability of blood flow to deliver oxygen and remove products of muscle metabolism. The symptom may be due to deconditioning, as in prolonged bed rest, or the presenting symptom in anemia of any causation. When cardiac output is reduced from any cause and cannot increase, the response to skeletal muscle metabolic demand during activity cannot be

(9)

met. The presence of obstructive vascular disease also limits the availability of blood flow and is a common cause of limb fatigue and of intermittent claudication.

Palpitations

This is an awareness of an unusual beating of the heart. Palpitations are common and may be benign or indicative of important heart disease. In general, the term refers to an awareness of an irregularity of the heartbeat. A patient also may be aware of either severe tachycardia or bradycar- dia, and the associated symptoms of lightheadedness or even syncope. As with the other symptoms of heart disease, the nature of the occurrence, precipitating and continuing factors, and the prior medical history are vital. The underlying causes of palpitations include ectopic beats, transient atrial fibrillation, and heart block. A sudden onset or offset favors paroxysmal atrial tachycardia or atrial flutter/fibrillation. “Flip-flops” favor premature ventricular contractions. A moderate unexplained increased in heart rate may favor an anxiety state. Again, the influence of other factors including fever, anemia, or hyperthyroidism must be considered.

Syncope

Syncope is defined as a loss of consciousness due to underperfusion of the brain. It may be due heart block, or in response to ventricular flutter or fibrillation. Syncope following effort occurs

Table 5 Causes of Dyspnea Pulmonary Disease

Acute

Spontaneous pneumothorax Pulmonary embolus Pneumonia Airway obstruction Subacute

Chronic obstructive lung disease Emphysema

Pulmonary fibrosis Chronic bronchitis Bronchiectasis Cardiac Disease

Acute

Pulmonary edema

Aortic/mitral valve insufficiency Prosthetic valve dysfunction Left atrial thrombus Left atrial myxoma Subacute

Heart failure

Myocardial infarction Pericardial effusion Constrictive pericarditis Other Causes

Intrathoracic malignancies Rib fracture, chest trauma Anxiety state

Hyperventilation

(10)

in association with aortic stenosis, but also in patients with hypertrophic cardiomyopathy and pulmonary hypertension. The differential diagnosis includes the common faint (vasovagal attack) and seizure disorders. This is discussed fully in Chapter 18.

Other Symptoms

Other symptoms of heart and vascular disease are listed in Table 6. Although these associations may not be frequent in regard to the specific symptom, such a possibility is important to consider.

Embolic stroke always requires a search for an intracardiac source, particularly atrial fibrillation and infective endocarditis, but also in patients post-myocardial infarction or with carotid artery disease. Embolic sources include left atrium, left ventricle, mitral and aortic valves, and the aorta and carotid arteries. Paradoxical embolism occurs by way of a patent foramen ovale.

Systemic findings of fever, rigors, and tachycardia associated with a new or changing murmur suggest infective endocarditis, but also may be due to rheumatic fever or atrial myxoma. Cardiac involvement may occur in a number of systemic disorders, including rheumatoid arthritis, lupus erythematosus, and scleroderma. Hematologic disorders affecting the heart include polycythemia vera, sickle cell anemia, and thalassemia. Cardiac involvement is common in cancer patients as a group. Acute leukemia, malignant melanoma, and Hodgkin’s disease are frequent causes of cardiac symptoms, as are interthoracic malignancies, in particular bronchogenic carcinoma and metastatic breast disease. Infiltrative disorders of the myocardium include amyloidosis and hemochromatosis.

CONCLUSION

The evaluation of the complaints of any patient reduces to a form of detection, a “who done it.” The astute clinician considers the medical history “the primary evidence” and then seek new clues—“forensic tests” and the like. Perhaps he or she revisits “the scene of the crime” with a second interview: “I did not understand how your father died. Please tell me.” We all rely on prob- abilistic or likelihood considerations, structured or unstructured, intuitive, instinctive, or scientifi- cally derived. Nevertheless, the taking of a medical history is somewhat of an art—a learned experience. It is application of a true “uncertainty principle”—inexactitudes in action. Yet from the patient’s perspective, “the verdict”—a solution to a specific issue, “the complaint”—is the purpose. This also is basic to our purpose as physicians and as to whether or not our derived conclu-

Table 6

Other Conditions and Symptoms Associated With Heart Disease General Symptoms of Infection—fever, sweating, malaise

Rheumatic fever Infective endocarditis Atrial myxoma

General Manifestations of Connective Tissue Diseases Systemic lupus erythematosus

Scleroderma Polymyositis Polyarteritis nodosa Muscular dystrophies

Progressive, myotonic, Freidrich’s ataxia Embolic disorders

Cerebral Hemiparesis

Transient/persistent visual disorder Manifestations of septic emboli occurring in:

Skin, digits, nail beds, spleen, kidney, limbs

(11)

sions are correct and our recommended treatments effective. But that is not the only outcome to be fostered. It also should be the basis for a continuing interaction between doctor and patient so as to result in a net gain in individual personal health, which is the fundamental purpose of medical practice.

REFERENCES

1. Wilson PWF, D’Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circu- lation 1998;97:1837–1847.

2. American College of Cardiology 27th Bethesda Conference. Matching the intensity of risk factor management with the hazard for coronary disease. J Amer Coll Cardiol 1996;27:958–1047.

3. Wilde O. The balade of Reading Gaol. The Works of Oscar Wilde. The Wordsworth Poetry Library, Hants, Ware, UK, 1994, pp. 136–152.

4. Mayo WJ. Aphorism # 78. In: Willius FW, ed. Aphorisms, 2nd ed. Rochester MN, Mayo Foundation, 1990, p. 67.

5. Swartz MH. The art of interviewing. In: Textbook of Physical Diagnosis, History and Examination, 3rd ed. W. B.

Saunders, Philadelphia, 1998, pp. 1–81.

6. Smith LH Jr. Medicine as an art. In: Cecil’s Textbook of Medicine. W. B. Saunders, Philadelphia, 1992, pp. 6–9.

7. Bennett JC. The social responsibilities and humanistic qualities of “the good doctor.” In: Cecil’s Textbook of Medicine. W. B. Saunders, Philadelphia, 1992, pp. 2–6.

8. Li JTC. Humility and the practice of medicine. Mayo Clin Proc 1999;74:529–530.

9. Webster’s College Dictionary. Random House, New York, 1992.

RECOMMENDED READING

Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination, 8th ed. Lippincott, Philadelphia, 2003.

Meador CK. A Little Book of Doctors’ Rules. Hanley and Belfus, Philadelphia, 1992.

Swartz MH. Textbook of Physical Diagnosis, History and Examination, 3rd ed. W. B. Saunders, Philadelphia, 1998.

Seidel HM, ed. Mosby’s Guide to Physical Examination, 5th ed. Mosby, St. Louis, 2003.

RA Gross. Making Medical Decisions. An Approach to Clinical Decision Making American College of Physicians- American Society of Internal Medicine, Philadelphia, 1999.

6 The Medical Historyand Symptoms of Heart Disease

6 The Medical History

and Symptoms of Heart Disease

H. J. C. Swan, MD , P

D

H. J. C. Swan, ^MD , ^P

^D