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Introduction – The Patient's History (Diagnostics)

by Joseph Alpert, MD
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    00:09 Welcome back! This is the third part in the “Cardiology: An Introduction” series.

    00:15 I would like to repeat what I said in an earlier lecture and that is, we are going to be covering a huge amount of material in a very short time. I don’t expect that you will become an expert in Cardiology from watching this series and I strongly recommend that if you have a deep and abiding interest in this area, that you follow up with reading in one of the references at the end of the lectures or in one of the standard textbooks of Cardiology.

    00:40 So, today we are going to talk about the history of the patient, the physical examination and the electrocardiogram - the three basic steps in making a cardiovascular diagnosis. Let’s start with the history. The history is the most important factor in making a diagnosis of heart or vascular disease. The patient has to tell us their chief complaint, in other words, why they came to see us as a Cardiologist. And then we follow that up with more detailed information about all the symptoms that they are having as well as look at their family history and their past history. If you don’t have the answer for the diagnosis by the time you are finished with the history, you are really already in trouble since 90% of the diagnostic information is in the history. Physical exam and the laboratory data are really used for confirmation. Now, let’s start by talking about the history.

    01:42 Of course, the patient will tell us some complaint, which will point us in the direction of which disease they might have. Thus, just to give you an example, the patient talks about chest discomfort, then we are thinking about atherosclerotic or hardening of the arteries, as it’s termed in the lay language, with restriction of blood flow into the heart muscle. If they are complaining about shortness of breath and swelling of the ankles, we are thinking about heart failure- in which the heart is not pumping efficiently enough. We also will be asking the patient questions about a number of lifestyle issues in order to understand what heart disease they are at risk for having. So, we will start with the history. In this, we usually ask the patient what brought them to see us and then we make a sort of series of questions that revolve around that major symptom. For example, chest discomfort or shortness of breath or marked fatigue and so forth. We will also take a past history in which we will try and find out if the patient has had a health problem in the past that relates to that. For example, this patient may tell us that they had a heart attack two years ago. Immediately, I know that I am going to be looking for further confirmation that their atherosclerotic heart disease has gotten worse in some way or it requires further diagnostic study and possible change of medication or intervention to make the patient feel better.

    03:30 Usually, the history can be taken in about 15 or 20 minutes. Less time doesn’t enable you really to dig in and get the full amount of information.

    03:42 During the past history, besides any obvious events that may have occurred, we will also be asking about various lifestyle things that can lead to a risk component of the disease.

    03:57 For example, have you been a cigarette smoker? Are you diabetic? Have you been told that you have high cholesterol and so forth? So, there are going to be a number of pieces of information that we will couple together to move us in the direction of the diagnosis, including what’s happened in the past. We’re also going to be interested, as I said, in lifestyle factors- Were you a smoker? Is your diet one that is heavy in animal products- meat and cheese and so forth? In other words, lots of saturated fat. Or have you been more modest in your diet? Have you ever been overweight or are you overweight now, so forth? A number of things like this including of course alcohol, exercise, all the things that can push the patient in the direction of atherosclerosis or not.

    04:47 As you will hear from a later lecture, atherosclerosis is very, very, very common. It’s the number one cause of death throughout the world and consequently, most of the patients I see, three quarters to 80% of these patients, the disease is going to be atherosclerotic heart disease. So, various risk factors for atherosclerosis are very important in the history - Is the patient got a lot of risk factors that suggest that they might have hardening of the arteries or atherosclerosis? Or have they got a number of factors in their life - exercise, not obese, not diabetic, not have high blood pressure, that would point you away from that diagnosis and towards another one. And here we see, of course, the major risk factors for atherosclerosis.

    05:34 Again, as I said, 75%-80% of my patients are going to be seeing me because of this disease, which is the commonest cause of death in the world today. So, I’m particularly interested in a history of cigarette smoking, diabetes, high fat diet, possible previous diagnosis of high cholesterol. Again, these are the major factors that point us in the direction of atherosclerosis. And of course, as we will see in a moment, family history is very important because it gives us some clue as to the genetics. If I am concerned about heart failure - patient complains of shortness of breath, then I am going to be asking, has there been ankle swelling? Is there been fatigue? The various symptoms that go with heart failure. If I’m more interested in chest pain and ischemic heart disease, I may be asking more questions about when does the pain occur and how severe and where in the chest and so forth. Again, the characteristics of risk factors for heart failure often are the same as those for ischemic heart disease because ischemic heart disease is often a cause of heart failure. So again, we are going to be looking for various risk factors, past history of heart attacks and so forth.

    06:53 We are also going to be very interested in the patient’s past history. So, here is a little example of an individual who had rheumatic fever as a child, remembers having severe arthritis and being kept in bed for a long period of time and now complains of shortness of breath. This is a disease which is particularly common in women and often result in marked shortness of breath during pregnancy when there is an extra burden placed on the heart in terms of pumping ability. The patient may complain of some swelling in their feet, they may complain of shortness of breath, they may have a difficult time sleeping at night and have to sit up because of shortness of breath and there will be characteristic findings on the physical exam as we will… as we will talk about later. In any case, the moment I hear a story of rheumatic heart disease, I know that I am very likely going to be looking for valvular heart disease rather than ischemic or atherosclerotic heart disease. So then, again, symptoms are going to be very, very important because they are going to point us in the direction of which possible heart disease is causing the symptoms and going to lead us in the direction of what tests we need to do to confirm the diagnosis before we start therapy. Having now obtained a history, both the family


    About the Lecture

    The lecture Introduction – The Patient's History (Diagnostics) by Joseph Alpert, MD is from the course Introduction to the Cardiac System.


    Included Quiz Questions

    1. Shortness of breath
    2. Diarrhea
    3. Paralysis
    4. Hallucinations
    1. Childhood measles
    2. Cigarette smoking
    3. Elevated serum cholesterol
    4. High blood pressure
    5. Diabetes mellitus

    Author of lecture Introduction – The Patient's History (Diagnostics)

     Joseph Alpert, MD

    Joseph Alpert, MD


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