FEAR OF HEART DISEASE
Diseases of the heart and circulation are so common and the laity is
so well acquainted with the major symptoms resulting from these disorders
that patients, and occasionally physicians, erroneously attribute
many noncardiac complaints to cardiovascular disease. The combination
of the widespread fear of heart disease with the deep-seated
emotional connotations concerning this organs function results in the
frequent development of symptoms that mimic those of organic disease
in persons with normal cardiovascular systems. The unraveling
of symptoms and signs due to organic heart disease from those not
directly related is an important and challenging task in such patients.
Patients in whom heart disease has been confirmed, especially those
who have experienced a major cardiovascular event such as a myocardial
infarction or a serious arrhythmia, are often frightened and
anxious about hospital discharge and resuming normal activity, including
sexual relations. Attention to these matters is vital in the care
of cardiac patients.
Dyspnea, one of the cardinal manifestations of heart failure, is not
limited to patients with heart disease but is also observed in conditions
as diverse as pulmonary disease, marked obesity, and anxiety (Chap.
29). Similarly, chest discomfort may result from a variety of causes
other than myocardial ischemia (Chap. 12). Whether heart disease is
responsible for these symptoms can frequently be determined by carrying
out a careful clinical examination. Noninvasive testing using
electrocardiography at rest and during exercise (Chap. 210), echocardiography
(Chap. 211), roentgenography, and myocardial imaging
usually provides important additional information to permit the correct
interpretation of symptoms; more specialized invasive examinations
(catheterization and angiography; Chap. 212)are occasionally necessary.
This is not supposed to be an alternative sheet to the clinical test, on the contrary it is no more than a clinical aid in history taking in conjunction with the clinical text.
Personal History:
Patient name, age, sex, profession, place of origin, current residence, marital status, parity (state the number of sons and daughters only)
Special habits of medical importance: (specify duration of each habit & clinical complications if any).
N.B. Do not start your personal history with the following: Name age etc .. (do not use titles) e.g. Hany, 45 yrs old male, engineer born in . & lives in ., married & has 2 sons.
Complaint:
Should always be:
- The single most important driving symptom that brought patient to medical advice (do not multiply symptoms in the complaint).
- Should be in English, never in Latin.
- Should include the onset, course & duration.
e.g. insidious, progressive right upper abdominal pain of 3wks duration (do not analyze the symptoms in this section).
Present history:
Should start with the following question:
When did the problem start? Or tell me when was the last time you have been feeling well?
The student should use one of these forms to start and date the present history.
The symptoms should be arranged chronologically with consideration to the symptom relevance.
For example, the patient may say "my legs were swollen and I notice that I became jaundiced" here the student should analyse lower limb edema first by asking direct questions like did you notice puffins in the eye lids? Did your abdomen got swollen as well? Before the patient takes him to jaundice and sequential arrays of symptoms.
The student should not move from one symptom to another unless each is fully analyzed.
GIT questionnaire must include: sore mouth, anorexia, pyrosis, heartburn, dysphagia, abdominal pain, distension, changing bowel habits "especially recent change in the bowel habit", hematemsis, melina, hematochezia.
Cardiopulmonary questionnaire: chest pain (this is a serious symptom and should be perfectly analyzed especially in middle age man), dyspnea (grading and different forms as PND, orthopnea, platypnea should be enquired), cough (dry or wet, diurnal or nocturnal, relation to posture), palpitations, wheezing, cyanosis.
Hematological symptoms: bleeding tendency, easy bruisability, hemolytic attacks, family members involved.
Nephrology questionnaire: flank pains, hematuria, stone passage, untreated hypertension, neglected diabetes, nephrotoxic drug history, renal failure subjects on dialysis.
Neurological questionnaire: headache of recent onset, dizziness and fainting, abnormal sensations (parasthesia), visual disturbances, sphincteric problems and seizures.
Muscukoskeletal questionnaire: joint pains (specify the joint involved and when do they get worse), muscle pains and weakness, nuchal and back pains.
The student should never forget to enquire about and probe other systems beyond the system of concern in the case. For example, if the patient is presenting with jaundice, ascites, and lower limb edema, here the student will be impressed by a chronic liver disease presentation and may forget completely to ask about cardiac symptoms which may be the reason behind the liver failure (e.g., cardiac cirrhosis).
Past history: Should include similar attacks, surgeries, blood transfusion, hospital admission, detailed drug history, diabetes and hypertension, fits and faints, traveling to endemic regions, contact with infectious cases, sexual history in relevant cases.
Family history:
Malignancy, diabetes, hypertension, similar condition in the family must all be elicited.
The student should learn in the last two minutes in the history taking process how to rearrange the key presenting symptoms in short and chronologically to make up a reasonable deductive summary of a history. He may ask the patient in the end if he would like to add any more information. The student should learn to take notes in his sheet concerning how the patient describe his symptoms, his facial expression during history taking, how he uses his hands to demonstrate his pains, etc..
excellent mirza!!!!!!!!!!!! thanq very much i have one Glassgow criteria-simplified Ransons criteria PANCREAS P-PaO2 A-albumin N- nitrogen C-calcium R-raisedTc E-enzymeLDH A-age S-sugar severe disease>3factors
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