Case Finding

The discovery of a previously unknown health problem, or case finding, may occur when an abnormality is found during the routine medical examination of a healthy patient or when a person becomes aware of a change in his or her state of health and seeks medical care. Periodic health examinations and examinations requested by someone's employer or insurer vary greatly in scope and thoroughness. A physical examination is mandatory. A variety of tests may be included in the examination, such as blood tests, an electrocardiogram, a chest X-ray, and treadmill stress tests. Some findings raise suspicion that a heart problem may be present:

abnormal heart sounds or murmurs

irregularities of the rhythm of the heart

elevated blood pressure

unusual shape or enlargement of the heart shadow in the X-ray film

abnormalities shown in the standard electrocardiogram

electrocardiographic abnormalities detected during a treadmill stress test

The discovery of an abnormality in a routine examination usually results in further evaluation to confirm or reject the suspicion of heart disease. Occasionally, findings are characteristic enough to make a firm diagnosis at once. Heart disease present at birth—congenital heart disease—may be discovered in the postnatal examination

or in a periodic examination performed during the first year of life.

The discovery of a previously unknown heart abnormality is a goal of preventive cardiology, but the commonest way heart disease is first detected is when a person becomes aware of certain symptoms and seeks medical care. Symptoms may signal an acute change in the state of health, requiring immediate attention, or they may be nondisabling and repetitive.

Acute events that may demand emergency medical care include sudden loss of consciousness, severe dizziness or faintness, severe chest pain, severe shortness of breath, or sudden onset of rapid heart action. Chronic or repetitive symptoms that most frequently lead to the discovery of heart disease are shortness of breath, chest pain, and palpitations.

Shortness of breath is a normal response to strenuous exercise and as such is not alarming. However, shortness of breath provoked by minor, previously well-tolerated activity or occurring during rest makes a patient aware of an abnormal respiratory effort. This abnormal shortness of breath, most often associated with diseases of the heart or lungs, is called dyspnea . Dyspnea may appear in patients resting in bed as a sudden onset of rapid breathing, often accompanied by coughing, or as discomfort when lying down if the patient can breathe comfortably only when sitting up. A special variety of dyspnea, hyperventilation, in which a person is compelled to breathe deeply and rapidly, is usually unrelated to serious abnormalities of the heart, being a response to abnormal signals from the brain that may occur in some anxious, otherwise healthy persons. As a manifestation of heart disease, dyspnea is usually related to impaired function of the left ventricle (see chap. 5).

Chest pain is the principal symptom of coronary disease. Inasmuch as chest pain may be produced by a variety of conditions, some inconsequential, identification of the cause of chest pain constitutes a real challenge to the physician. Other causes of chest pain include pericarditis, aortic dissection, spasm of the esophagus, and pleurisy. In many cases, chest pain originates in the muscles or nerves within the chest wall and does not indicate a significant health problem.

Ordinarily a person is not aware of the beating of the heart, although it often seems to "pound" during strenuous exercise, excitement,

or fright. Palpitations refer to unprovoked perception of unusual heart action, often occurring at rest. A patient may recognize the heart beating too slowly, too fast, or irregularly. Thus palpitations suggest an abnormality of the rhythm of the heart (arrhythmia ).

These three symptoms motivating a person to seek medical care account for the majority of discoveries of a previously unknown heart disease. They may, however, indicate a health problem of a different nature, or none at all. Less frequently, heart disease is discovered in patients who consult physicians for other symptoms: dizziness, excessive weakness, fainting attacks, swelling of ankles, abdominal discomfort, and so on.