In the evaluation of patients with definite or suspected heart disease, important information (when sought) can be acquired from the history, physical examination, chest radiography, electrocardiography, and other routine laboratory tests. In fact, this approach has recently undergone the increasing scrutiny of evidence-based clinical diagnosis.1 These data, when integrated properly, facilitate an accurate diagnosis and appropriate decisions regarding therapy in many patients at a relatively low cost. When more information is necessary, additional, more expensive noninvasive cardiac tests such as echocardiography or radionuclide studies are often indicated. In some patients, the general assessment indicates the need for cardiac catheterization and contrast angiography with or without additional noninvasive cardiac testing. For example, the proper approach to certain, but not all, patients with symptomatic coronary artery disease (CAD) may include both coronary arteriography and cardiac catheterization (anatomy and hemodynamics) as well as myocardial perfusion imaging with thallium or technetium sestamibi (extent of inducible ischemia).
Not all patients need every test; the skillful use of low-technology approaches, including the history and general examination (when properly performed), can preclude the need for additional testing or can indicate which of a variety of available sophisticated tests should be selected for a particular patient. This chapter is divided into three sections. The first concerns the proper application of the history and its use to delineate the differential diagnosis in patients who present with certain common cardiovascular symptoms. The second details the essential components of the general physical examination and their usefulness in establishing a likely diagnosis when specific abnormal findings are detected. Finally, the third section focuses on cardiac auscultation.
Components of Accurate History Taking
A carefully obtained history is the cornerstone for evaluating a patient with known or suspected cardiac disease.2 A deliberate, compassionate interview forms the basis for a patient–physician relationship that can continue indefinitely. Unfortunately, the interview can result in adversarial roles for physician and patient if the interviewer appears hurried, shows impatience, fails to establish eye contact, seems to treat dreaded diseases casually, or appears to be unsympathetic. When the medical interview is unsatisfactory because of poor communication and lack of rapport, inaccurate information and often unnecessary testing will be obtained. Also, important facts not revealed during a meticulous initial history are usually not detected later because both the patient and physician become focused on high-technology studies and more aggressive therapeutic interventions.
The patient's chief complaint, which requires further elaboration and investigation, may not identify his or her most serious problem. Therefore, symptoms other than the patient's chief complaint must be defined. The interviewer should note all existing symptoms and establish a present illness for each of these.
A medical questionnaire given to the patient well in advance of the interview is useful and can record important data more accurately because of the time thus made available to reflect and check details.
A proper interpretation of the past ...