CHAPTER 11: THE HISTORY, PHYSICAL EXAMINATION, AND CARDIAC AUSCULTATION

INTRODUCTION

The history and physical examination have always been the cornerstone of the evaluation of the patient with known or suspected cardiovascular disease. In the past five decades, there has been an unprecedented development and implementation of cardiovascular diagnostic modalities, which provide high-resolution, real-time images of cardiac structure and measurements of cardiac function. The new generation of cardiovascular specialists is now relying more and more on the results of these tests to make clinical decisions, with decreasing emphasis on teaching and performing a proper history and physical examination. However, optimal patient care should use cardiovascular testing to confirm and supplement the clinical impression based on the history and examination—not replace it.

The initial interview with the patient is a necessity that has not changed over the decades. A properly taken history not only provides the richest source of clinical information regarding a patient’s illness, but is key to understanding the effect of the illness on the patient and family as well as individual needs and preferences. This knowledge, as well as the compassion and empathy that the physician can extend to the patient and family during this initial interaction, is of great importance not only in the clinical decision making but also in forming a trustful patient-physician relationship. It is important to always listen to patients. There are frequently subtle clues to the diagnosis that may be revealed by careful interrogation, but many times other clues are spontaneously brought forth by patients themselves. Finally, patients now present with multiple medical problems in addition to the cardiovascular problem, and a thorough history will provide insight into any contribution of noncardiac causes to the new onset or exacerbation of symptoms.

With the widespread availability of cardiac imaging, there has been an evolution in the detail and focus of the physical examination. It is no longer necessary to be able to obtain all the necessary information from the examination, because the imaging modalities will provide diagnostic and hemodynamic results with a greater degree of certainty and accuracy than even a master clinician can achieve. For instance, maneuvers performed on a patient with a diastolic rumble to differentiate mitral stenosis from an Austin-Flint murmur are no longer relevant; the question is easily answered from a comprehensive two-dimensional and Doppler echocardiogram. The severity of mitral stenosis is much more accurately obtained from a transmitral Doppler gradient as opposed to the subjective assessment of the A2-opening snap interval on the examination.

However, a well-performed physical examination is necessary to provide an initial clinical impression of the type and severity of cardiac disease as well as its effect on the patient. The subsequent diagnostic studies should then be used to confirm or refute this initial impression, ...