Heart Disease [antikvár]

Part I Examination of the Patient Chapter1 The History EUGENE BRAUNWALD IMPORTANCE OF THE HISTORY 1 The Role of the History 1 Technique 1 CARDINAL SYMPTOMS OF HEART DISEASE 2 Dyspnea 2 Chest Pain or Discomfort 3 Cyanosis 7 Syncope 8 Palpitation 9 Edema 9 Cough 10 Hemoptysis 10 Fatigue and Other Symptoms 10 THE HISTORY IN SPECIFIC FORMS OF HEART DISEASE 10 Heart Disease in Infancy and Childhood ... .11 Myocarditis and Cardiomyopathy 11 High-Output Heart Failure and Cor Pulmonale 11 Pericarditis and Endocardltis 11 Drug-lnduced Heart Disease 11 Assessing Cardiovascular Disability 13 REFERENCES 13 IMPORTANCE OF THE HISTORY Specialized examinations of the cardiovascular system, presented in Chapters 3 to 11, provide a large portion of the data base required to establish a specific anatomical diagnosis of cardiac disease and to determine the extent of functional impairment of the heart. The development and application of these methods represent one of the triumphs of modern medicine. However, their appropriate use is to supplement but not to supplant a careful clinical examination. The latter remains the cornerstone of the assessment of the patient with known or suspected cardiovascular disease. There is a temptation in cardiology, as in many other areas of medicine, to carry out expensive, uncomfortable, and occasionally hazardous procedures to establish a diagnosis when a detailed and thoughtful history and physical examination are sufficient. Obviously, it is undesirable to subject patients to the unnecessary risks and expenses inherent in many specialized tests when a diagnosis can be made on the basis of an adequate clinical examination or when management will not be altered significantly as a result of these tests.1 Intelligent selection of investigative procedures from the ever-increasing array of tests now available requires far more sophisticated decision-making than was necessary when the choices were limited to electrocardiography and chest roentgenography; somé of the principles in such decision-making are dealt with in Chapters 11 and 53. The history and physical examination provide the critical information necessary for most of these decisions. THE ROLE OF THE HISTORY. The overreliance on laboratory tests has increased as physicians attempt to utilize their time more efficiently by delegating responsibility for taking the history to a physician's assistant or nurse or even by limiting the history to a questionnaire-an approach that I consider to be an undesirable trend insofar as the patient with known or suspected heart disease is concerned.2 First, it must be appreciated that the history remains the richest source of information concerning the patient's illness,3'4 and any practice that might diminish the quality or quantity of information provided by the history is likely ultimately to impair the quality of care. Second, the physician's attentive and thoughtful taking of a history establishes a bond with the patient that may be valuable later in securing the patient's compliance in following a complex treatment plan, undergoing hospitalization for an intensive diagnostic work-up or a hazardous operation, and, in somé instances, accepting that heart disease is not present at all. Taking a history alsó permits the physician to evaluate the results of diagnostic tests that have strong subjective components, such as the determination of exercise capacity (Chap. 5). Perhaps most importantly, a careful history allows the physician to evaluate the impact of the disease, or the fear of the disease, on the various aspects of the patient's life and to assess the patient's personality, affect, and stability; often it provides a glimpse of the patient's responsibilities, fears, aspirations, and threshold for discomfort as well as the likelihood of compliance with one or another therapeutic régimén. Whenever possible, the physician should question not only the patient but alsó relatives or close friends to obtain a clearer understanding of the extent of the patient's disability and a broader perspective concerning the impact of the disease on both the patient and the family. (For example, the patient's spouse is much more likely than the patient to provide a history of Cheyne-Stokes [periodic] respiration.) The combination of the widespread fear of cardiovascular disorders and the deep-seated emotional, symbolic, and sometimes even religious connotations surrounding the heart may, on the one hand, provoke symptoms that mimic those of organic heart disease in persons with normál cardiovascular systems. On the other, they cause so much fear that serious symptoms are repressed or denied by patients with established heart disease. TECHNIQUE. Several approaches can be employed successfully in obtaining a medical history. I believe that pa-