The Initial Medical Examination

In the initial contact with a patient suspected of having heart disease, the physician takes a complete medical history and performs a physical examination. The medical history is largely devoted to a detailed analysis of the patient's symptoms. The patient's ability to present a well-observed, reliable, and consistent account of symptoms is essential in helping the physician draw correct conclusions. The medical history also includes background information, such as past medical problems, a family medical history, a social and occupational assessment, and an evaluation of the patient's personality.

During the initial interview the physician takes note of the patient's general appearance and his or her concern regarding the possibility of serious illness. Certain abnormalities may become obvious: shortness of breath while talking, unusual pallor, cyanosis, and strain in performing minor activities such as walking into the room or dressing. Such observations do not necessarily point to a heart problem but could, supported by the patient's history, make the physician suspect heart disease.

A complete physical examination focuses on those areas of concern revealed in the history taking and initial observations. The contribution of the physical examination to the diagnosis of heart disease varies widely: sometimes, although serious heart disease is present, the findings of the physical examination may be normal; at other times, a definitive diagnosis can be made on the basis of the medical history and physical examination without further tests.

Cardiac auscultation—listening to the heart with a stethoscope on the front of the chest—is an important part of the examination. In a healthy person cardiac auscultation reveals two normal heart sounds produced by the action of heart valves. Abnormal findings suggesting heart disease include certain alterations of the normal sounds and the presence of additional sounds and heart murmurs. Heart murmurs occur when a normal, smooth, "laminar" blood flow becomes turbulent. Turbulence arises when there is an obstacle in the path of blood flow, such as narrowing of a heart valve, backflow through an incompetent heart valve, or an abnormal communication between the right and the left sides of the heart or between certain large blood vessels. (Murmur due to turbulent flow may be present in healthy subjects as well, particularly in children after acceleration or increase of blood flow such as during exercise. Such murmurs are usually referred to as "functional" or "innocent.") Thus the discovery of a heart murmur can help the physician diagnose diseases of heart valves and certain congenital defects of the heart. Other abnormal findings on auscultation include a "friction rub," usually indicating pericarditis; extra heart sounds, which may be related to impaired function of the heart; and abnormal clicks or snaps originating in malfunctioning valves.

Other parts of the physical examination providing diagnostic information in heart disease include taking the arterial pulse, observing the venous pulse, and measuring the blood pressure. Serious malfunction of the heart (congestive heart failure ) may be signaled by abnormalities of the venous pulse in the neck, the presence of rales (bubbling noises during breathing), enlargement of the liver, and the accumulation of fluid in the ankles, around the lungs, and in the abdominal cavity. A physician can perceive abnormalities of the heart rhythm by feeling the pulse at the wrist. However, a more detailed analysis requires listening to the sequence of heartbeats with the stethoscope, sometimes combined with observing the venous pulse.

After completing the medical history and physical examination, the physician can sometimes establish a definitive diagnosis or rule out heart disease. Usually, however, the result of the initial workup is a tentative diagnosis or a list of illnesses to be considered. The next step is to select further diagnostic procedures. A wide range of tests is now available to aid in the diagnosis of heart disease, from

simple ones performed in the office to complex hospital procedures, some entailing risk to the patient. It is customary to classify diagnostic heart tests as noninvasive , wherein all instruments used in the test remain outside the body, and invasive , requiring the introduction of catheters or other instruments into the body. Invasive diagnostic procedures also include certain minor operations.