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CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
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Chapter Summary
This chapter presents a modern approach to physical examination in cardiovascular disease (CVD), correlating bedside findings with echo-Doppler-derived and invasive hemodynamics. The patient’s history and a physical examination have always been the central component of the clinical evaluation of CVD. Findings on palpation, inspection, and auscultation are reflective of the underlying hemodynamics (see Fuster and Hurst’s Central Illustration). Although there have been tremendous advances in noninvasive testing over the past 50 years, history-taking and physical examinations are still essential in providing the pretest probability for subsequent diagnostic testing. A final diagnosis will be made only when there is agreement between the clinical assessment and test results; when discordance is present, further assessment is needed.
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We are in danger of losing our clinical heritage and pinning too much faith in figures thrown up by machines. Medicine will suffer if this tendency is not checked. —Paul Wood (1950)1
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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 unprecedented development and implementation of cardiovascular diagnostic modalities that 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 involve cardiovascular testing to confirm and supplement the clinical impression based on the history and examination—not replace it.
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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. However, many times, other clues are spontaneously brought forth by patients. 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.
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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 ...