The Patient History

Kazue Okajima

Richard A. Lange

HISTORY: KEY STEP IN DIAGNOSIS

Obtaining a detailed history is crucial to the proper evaluation of the patient with suspected cardiovascular disease and the first step in establishing the provider-patient relationship. The time spent with the patient, the attitude the provider displays, and the listening skills exhibited by the provider set the tone for the relationship. In addition to gaining information about the patient’s health condition(s), obtaining the history is an opportunity to display to the patient that the provider is a compassionate person who cares about the individual’s condition and genuinely wants to help. The relationship that is built on strong communication skills with attention to details during the interview is more likely to lead to a complete and candid history that may avert unnecessary, expensive, and potentially hazardous diagnostic testing.

Studies show that physicians are able to collect 60% to 80% of the information relevant for a diagnosis by taking a detailed medical history, which leads to a final diagnosis in more than 70% of cases.¹,²,³,⁴ Conversely, inaccurate and/or incomplete patient histories are among the leading causes for diagnostic errors.⁵

In the era of extensive testing, the “art” of history taking is often neglected. Additionally, patient overload, multitasking, time constraints, and lack of available interpreters may interfere with taking a complete history. However, taking the time to listen to patients improves rapport with and trust from patients, patient recall of information, patient and physician satisfaction, adherence to therapy, and patient health outcomes.⁶,⁷,⁸

The history is not only an opportunity to elicit symptoms, but it may also reveal the influences of other medical conditions, identify risk factors that increase the likelihood of cardiovascular disease, and provide insight into the patient’s compliance with prescribed treatment. The history should be obtained directly by the health care provider caring for the patient rather than being delegated to another individual or collected from the medical record, in order for the provider to assess the patient’s medical knowledge, comprehension of their condition, attitudes, desires, trust, and treatment preferences.

Although certain elements of the social history are routinely obtained to ascertain if the individual is at risk of cardiovascular disease (ie, diet, exercise, alcohol intake, smoking history), other valuable aspects are often ignored. Illicit drug use is associated with myocardial infarction (MI), cardiomyopathy, and endocarditis; however, patients are often not questioned about it. Identifying the patient’s exposure to areas where Lyme disease, Chagas disease, rheumatic fever, or tuberculosis is endemic may provide insight into the etiology of conduction system disease, cardiomyopathy, valvular disease, and pericarditis. Finally, the socioeconomic status of the patient is known to be a risk factor for heart disease and predictive of the patient’s access to care and compliance with treatment.

Obtaining a detailed family history is also important, because many cardiovascular disorders are heritable, including arrhythmias (atrial fibrillation, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, long QT syndrome, short QT syndrome), congenital heart disease (Holt-Oram syndrome, supravalvular aortic stenosis, bicuspid aortic valve), coronary artery disease (CAD), cardiomyopathy (hypertrophic, dilated, restrictive, left ventricular noncompaction, and arrhythmic right ventricular dysplasia), cardiac tumors (Carney complex), vascular disease (Marfan syndrome, Ehlers-Danlos syndrome, familial thoracic aortic aneurysm, Loeys-Dietz syndrome), and lipid abnormalities (autosomal dominant [PCSK9] hypercholesterolemia, familial hypercholesterolemia).

Tools are available for patients and health professionals (www.hhs.gov/familyhistory) that (1) facilitate the procurement and organization of a detailed family history in the form of a pedigree and (2) provide the basis for appropriate diagnostic testing in family members of patients with suspected heritable cardiovascular disease. An up-to-date listing of health (including cardiac) conditions with genetic inheritance patterns is available at https://ghr.nlm.nih.gov/condition

CARDIAC DISEASE SYMPTOMS

The major symptoms associated with cardiac disease (ie, myocardial ischemia, heart failure, arrhythmias) include chest discomfort, dyspnea, edema, fatigue, palpitations, and syncope. Assessment of symptom severity is useful for assessing functional limitation, documenting improvement (or worsening) of the condition, and assessing response to therapy. Accordingly, clinicians and researchers often use semiquantitative activity scales—the New York Heart Association (NYHA) or Canadian Cardiovascular Society (CCS) functional classification systems—to assess symptom severity (Table 1.1).⁹

TABLE 1.1 Activity Scales Used to Assess Functional Capacity

Class	New York Heart Association (NYHA)	Canadian Cardiovascular Society (CCS)	Specific Activity Scale
I	Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.	Ordinary physical activity does not cause angina, such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation	Patient can perform to completion any activity requiring ≥7 metabolic equivalents.
II	Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.	Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions	Patient can perform to completion any activity requiring ≥5 metabolic equivalents but cannot or does not perform to completion activities requiring ≥7 metabolic equivalents.
III	Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.	Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace	Patient can perform to completion any activity requiring ≥2 metabolic equivalents but cannot or does not perform to completion any activities requiring ≥5 metabolic equivalents.
IV	Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.	Inability to carry on any physical activity without discomfort—anginal syndrome may be present at rest.	Patient cannot or does not perform to completion activities requiring ≥2 metabolic equivalents.
Data from Goldman L, Hashimoto B, Cook EF, Loscalzo A, et al. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation. 1981;64(6):1227-1234.

Chest Discomfort

Chest discomfort may be the primary symptom in a number of cardiac and noncardiac conditions. A careful history that pays attention to specific characteristics of the chest discomfort—location, quality, duration, inciting events, radiation, alleviating factors, and associated symptoms—is often sufficient to recognize noncardiac etiologies of chest pain (Table 1.2). This is important because less than 10% of patients with chest pain in the primary care setting are ultimately identified as having a coronary cause for their symptoms.¹⁰

Angina is typically a retrosternal, pressure-like discomfort that may radiate to the jaw, neck, left shoulder, left arm, back, or epigastrium. Various adjectives are often used by patients to describe the pain, including “crushing,” “squeezing,” “pressure-like,” “gripping,” and “suffocating,” or they may refer to it as “heaviness” or “fullness.” Not uncommonly, they insist that it is a “discomfort,” rather than a “pain.” Angina is almost never sharp or stabbing in quality, and it usually does not change with position or respiration. Atypical presentations of angina may include indigestion, belching, and dyspnea and are more common in women, older patients, and patients with diabetes.

Stable Angina

Angina is also characterized as stable or unstable. Stable angina usually is precipitated by physical exertion, emotional stress, eating a meal, or exposure to cold, and it is readily relieved by rest or nitroglycerin. The anginal episode typically lasts only a few minutes; fleeting discomfort for a few seconds or a dull ache lasting for hours is rarely angina. The term “chronic stable angina” refers to angina that has been stable in frequency and severity for at least 2 months. Chronic stable angina is the initial manifestation of coronary heart disease (CHD) in about half of the patients; the other half initially experience unstable angina, MI, or sudden death.

Chest Pain in Risk Assessment of Patients With Stable Angina. In individuals with stable chest discomfort, U.S. and European guidelines recommend using a diagnostic strategy based on the individual’s pretest probability of obstructive CAD.¹¹,¹²,¹³ For example, individuals with chest discomfort who are determined to have a low probability of obstructive CAD
usually do not need further cardiac investigation, those with an extremely high pretest probability may proceed directly to invasive angiography, and individuals with an intermediate probability are recommended to undergo evaluation with noninvasive cardiovascular imaging. Determining whether or not the patient has “typical” angina is an integral feature of all clinical risk assessments that are currently used to predict the likelihood of obstructive CAD.

TABLE 1.2 Differential Diagnosis of Chest Pain

Diagnosis		Characteristics	Comments
Ischemic heart disease		Typical or atypical angina	Caused by diminished coronary blood flow and/or increased myocardial oxygen demand
Nonischemic heart disease		Palpitations or typical angina	Tachycardia
	Arrhythmias Valvular heart disease Aortic dissection Pericarditis	Typical angina, often exertional “Tearing” pain, often abrupt onset Pleuritic pain, relieved by sitting up and leaning forward	Heart murmur present Widened mediastinum, often with hypertension Friction rub may be present; diffuse ST segment elevation (PR segment depression) on electrocardiogram
Pulmonary disease
	Pulmonary embolus	Pleuritic pain (sharp, worse with inspiration), associated dyspnea	Hypoxia/hypoxemia, pulsus paradoxus, and risk factors for thromboembolic disease
	Pneumothorax	Acute onset, pleuritic pain, associated dyspnea	Hyperresonance; tension pneumothorax associated with distended neck veins, hypotension, and tachycardia
	Pneumonia	Pleuritic pain, associated fever and cough	Associated with fever and productive cough
Gastrointestinal disease
	Esophageal disease	May be indistinguishable from angina (ie, relieved with nitroglycerin), may note regurgitation of food and relief with antacids	Often diagnosed following a negative evaluation for ischemic heart disease
	Gastritis, peptic ulcer disease	May be indistinguishable from angina	May be exacerbated by alcohol and aspirin and relieved by food and antacids
	Biliary disease	Right upper quadrant pain that radiates to the back or scapula	Exacerbated by fatty foods
	Pancreatitis	“Boring” epigastric pain, may radiate to the back	Typically worse following meals
Chest wall or dermatologic pain
	Costochondritis Rib fracture Herpes zoster	Reproduced with palpation or movement Point tenderness Point tenderness
	Fibrositis	Follows a nerve distribution/dermatome Characteristic point tenderness	Pain may precede rash
Psychiatric disorders
		Nonexertional, often associated with anxiety, hyperventilation, perioral paresthesia, and “panic attacks”	Often diagnosed following a negative evaluation for angina Often associated with palpitations, sweating, and anxiety
	Anxiety disorders Affective disorders (eg, depression) Somatoform disorders Thought disorders (eg, fixed delusions) Factitious disorders (eg, Munchausen syndrome)

Typical angina has three characteristic features (Table 1.3): the chest discomfort is (1) substernal; (2) initiated by exertion or stress; and (3) relieved with rest or sublingual nitroglycerin. Chest discomfort with only two of these characteristics is considered atypical angina. If none or only
one of the characteristics is present, it is considered nonanginal chest discomfort.

TABLE 1.3 Traditional Classification of Chest Pain

Typical angina (definite)

Meets all three of the following characteristics:

substernal chest discomfort of characteristic quality and duration
provoked by exertion or emotional stress
relieved by rest and/or nitrates within minutes

Atypical angina (probable)

Meets two of the above-mentioned characteristics

Nonanginal chest pain

Lacks or meets only one or none of the above-mentioned characteristics

The first score to calculate the pretest probability of obstructive CAD introduced more than three decades ago by Diamond and Forrester (the DF score) was calculated on the basis of the chest pain type (typical, atypical, or nonanginal chest pain), sex, and age. Subsequent studies demonstrated that the predictors selected by Diamond and Forrester are robust; however, their calibration was not adequate for the modern population of patients investigated for CAD. Accordingly, many centers in the United States utilize the Duke Clinical Score instead (Table 1.4), which includes modifiable cardiovascular risk factors. The most recent European Society of Cardiology (ESC) guidelines for stable CAD have replaced the DF score with two new revised scores, the CAD Consortium Basic and Clinical scores (Table 1.4).

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Tags: Cardiovascular Medicine and Surgery

May 8, 2022 | Posted by drzezo in CARDIOLOGY | Comments Off

Thoracic Key

Fastest Thoracic Insight Engine

The Patient History

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Thoracic Key

Fastest Thoracic Insight Engine

The Patient History

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