The patient’s history is a critical feature in the evaluation of suspected or overt heart disease. It includes information about
the present illness, past illnesses, and the patient’s
family. From this information, a chronology of the patient’s
disease process should be constructed. Determining what information
in the history is useful requires a detailed knowledge of the pathophysiology
of cardiac disease. The effort spent on listening to the patient
is time well invested because the cause of cardiac disease is often
discernible from the history.
Chest pain is one of the cardinal symptoms (Table
1–1) of ischemic heart disease, but it can also occur
with other forms of heart disease. The five characteristics of ischemic chest
pain, or angina pectoris, are
- Anginal pain usually has a substernal location but may
extend to the left or right chest, the shoulders, the neck, jaw, arms,
epigastrium, and, occasionally, the upper back.
- The pain is deep, visceral, and intense; it makes the patient
pay attention but is not excruciating. Many patients describe it
as a pressure-like sensation or a tightness.
- The duration of the pain is minutes, not seconds.
- The pain tends to be precipitated by exercise or emotional
- The pain is relieved by resting or taking sublingual nitroglycerin.
Table 1–1. Commom Symptoms of Potential Cardiac Origin. |Favorite Table|Download (.pdf)
Table 1–1. Commom Symptoms of Potential Cardiac Origin.
|Chest pain or pressure|
|Dyspnea on exertion|
|Paroxysmal nocturnal dyspnea|
|Syncope or near syncope|
|Transient neurologic defects|
A frequent complaint of patients with a variety of cardiac diseases, dyspnea is ordinarily one of four types. The most common is exertional dyspnea, which usually means that the underlying condition is mild because
it requires the increased demand of exertion to precipitate symptoms.
The next most common is paroxysmal nocturnal dyspnea, characterized
by the patient awakening after being asleep or recumbent for an
hour or more. This symptom is caused by the redistribution of body fluids
from the lower extremities into the vascular space and back to the
heart, resulting in volume overload; it suggests a more severe condition.
Third is orthopnea, a dyspnea that occurs immediately on assuming
the recumbent position. The mild increase in venous return (caused
by lying down) before any fluid is mobilized from interstitial spaces
in the lower extremities is responsible for the symptom, which suggests
even more severe disease. Finally, dyspnea at rest suggests severe
Dyspnea is not specific for heart disease, however. Exertional dyspnea, for example, can be due to pulmonary disease, anemia, or
deconditioning. Orthopnea is a frequent complaint in patients with chronic
obstructive pulmonary disease and postnasal drip. A history of “two-pillow
orthopnea” is of little value unless the reason for the
use of two pillows is ...