arise as a reflex in diseases of some other organs, in fever, anemia, neurosis, hyperthyroidism, and after administration of some medicinal preparations (atropine sulphate, etc.). Palpitation may also occur in healthy persons under heavy physical load, during running, emotional stress, smoking or coffee abuse. Patients with serious heart diseases may feel palpitation constantly, or it may arise in attacks of paroxysmal tachycardia.
Some patients complain of intermissions (escaped beats) which are due to disorders in the cardiac rhythm. Intermissions are described by the patient as the feeling of sinking, stoppage of the heart. Questioning the patient is aimed a determining the circumstances under which intermissions develop. They may arise at rest and physical exercises; they may be intensified in special postures of the patient, etc.
Pain in the heart region is an important and informative sign. The character of pain is different in various diseases of the heart. The physician should determine (by questioning) the location of the pain, the cause or condition under which it develops (exercise, emotional stress, walking, attack of pain at rest, during night sleep), the character of pain (acute, boring, piercing, a feeling of heaviness or retrosternal pressure, small boring pain in the region of the apex), duration and radiation of pain, conditions under which the pain abates. Pain often develops due to acute insufficiency of the coronary circulation, which results in myocardial ischemia. This pain syndrome is called stenocardia or angina pectoris. In angina pectoris pain is retrosternal or slightly to the left of the sternum; it most commonly radiates to the region under the left scapula, the neck, and the left arm. The pain is usually associated with exercise, emotional stress, and is abated by nitroglycerin. Angina pectoris pain occurs mostly in patients with coronary atherosclerosis but it may arise in inflammatory diseases of the vessels, e.g. rheumatic vasculitis, syphilitic mesaortitis, periarteritis nodosa, and also in aortal heart diseases and grave anemia.
Pain is especially intense in myocardial infarction and, unlike in angina pectoris, it persists for a few hours, and sometimes for several days. It does not abate after vasodilatory preparations are given. Pain in dissecting aneurysm of the aorta is piercing (like in myocardial infarction). Unlike in myocardial infarction, pain radiates usually to the spinal column, and moves gradually along the course of the aorta. Myocarditis is characterized by intermittent and pressing pain; it is dull, mild, and is intensified during exercise. Pain in pericarditis is located at the middle of the sternum or throughout the entire cardiac region; the pain is stabbing or shooting, and is intensified during movements, cough, even under the pressure of a stethoscope; the pain may persist for several days or arise in attacks. Permanent pain behind the manubrium sterni that does not depend on exercise or emotional stress (the so-called aortalgia) occurs in aortitis. Stabbing pain at the heart apex that arises in emotional stress or fatigue is
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characteristic of cardioneurosis. It should be remembered that pain in the cardiac region may arise due to affections of intercostal muscles, nerves, pleura, or the-adjacent organs (diaphragmatic hernia, cholecystitis, ulcer, gastric cancer).
Patients with heart diseases often complain of cough which is due to congestion in the lesser circulation. The cough is usually dry; sometimes a small amount of sputum is coughed up. Dry cough is also observed in aortal aneurysm because of the stimulation of the vagus nerve. Hemoptysis in grave heart diseases is mostly due to congestion in the lesser circulation and rupture of fine bronchial vessels (e.g. during coughing). Hemoptysis mostly occurs in patients with mitral heart disease. It may occur in embolism of the pulmonary artery. When the aneurysm opens into the respiratory ducts, profuse bleeding occurs.
Venous congestion in the greater circulation occurs in severe heart diseases with circulatory insufficiency. The patients would complain of edema, which first develops only in the evening and resolves during the night sleep. Edema occurs mostly in the malleolus region and on the dorsal side of the foot; shins are then affected. In graver cases when fluid is accumulated in the abdominal cavity (ascites) the patient would complain of heaviness in the abdomen and its enlargement. Heaviness most commonly develops in the right hypochondrium due to congestion and enlargement of the liver. In rapidly developing congestion, pain is felt in this region due to distention of the liver capsule. Patients may complain also of poor appetite, nausea, vomiting, and swelling of the abdomen. These symptoms are associated with disordered blood circulation in the abdominal organs. The renal function is upset for the same reason and diuresis decreases.
Patients with cardiovascular pathology often have dysfunction of the central nervous system, which is manifested by weakness, rapid fatigue, decreased work capacity, increased excitability, and deranged sleep.
Complaints of headache, nausea, noise in the ears or the head are not infrequent in essential hypertension patients.
Some heart diseases (myocarditis, endocarditis, etc.) are attended by elevated (usually subfebrile) temperature; sometimes high fever may occur. The patient should be asked about the time of the day when the temperature usually rises, how long it persists and if this rise is accompanied by chills, profuse sweating, etc.
History of present disease
The time of the onset of the disease and its first symptoms should be determined such as pain, palpitation, dyspnea, elevation of the arterial pressure, the character and intensity of these symptoms, connection with infections and other diseases of the past, cooling, and physical overloads. The character of development of the primary symptoms is important. It is also necessary to find out if any treatment was given and its effect, if any. If there
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were exacerbations of the disease, their course and causes should be established.
Anamnesis
Special attention should be paid to various possible causes of the present heart disease. Information should be carefully collected concerning diseases of the past, especially such diseases as rheumatism, frequent tonsillitis, diphtheria, syphilis, which would normally provoke cardiovascular pathology. It is important to know the unfavourable living and working conditions, chronic exposure to cold and high humidity, nervous and psychic overstrain, hypodynamia, overeating, occupational hazards, smoking and alcohol abuse and other harmful habits. It is also important to ask the patient about cardiovascular diseases that occurred in his relatives, because familial predisposition to some heart diseases is possible. It is necessary to inquire women about past pregnancies and labor, the onset of menopause because sometimes symptoms of cardiovascular pathology develop in them during this period.
General inspection
The general appearance of the patient, his posture in bed, colour of the skin and visible mucosa, the presence or absence of edema, the shape of the distal finger phalanges (drum-stick fingers) and of abdomen should be assessed. Patients with a marked dyspnea usually assume a half-sitting position; if dyspnea is grave, the patient assumes a forced position; he sits in bed with the legs on the floor (orthopnea). Greater portion of blood is retained in the vessels of the lower extremities in this position to decrease the volume of the circulating blood and congestion in the lesser circulation. Lung ventilation is thus improved. Furthermore, the diaphragm descends in the orthopnoeic position; if ascites is present, the pressure of the ascitic fluid on the diaphragm is lessened to facilitate respiratory excursions of the lungs and to improve gas exchange.
Patients with exudative pericarditis choose to sit in bed slightly leaning forward. Patients with enlargement of the heart lie on the right side because they feel discomfort when lying on the left side (the dilated heart more tightly presses the anterior wall of the chest).
Cyanotic skin is a common sign of heart diseases. In patients with circulatory disorders, cyanosis is more pronounced in parts of the body that are farther remoted from the heart, i.e. the fingers and toes, the tip of the nose, the lips, and the ear lobes. This phenomenon is known as acrocyanosis. It depends on the increased content of reduced hemoglobin in the venous blood because of excessive oxygen absorption by tissues in slow blood circulation. In other cases, cyanosis becomes central in conditions of oxygen hunger of blood due to its insufficient arterialization in the pulmonary bed. The degree of cyanosis varies from a slightly detectable blue tinge to the dark
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blue colour. Cyanosis is especially pronounced in patients with congenital heart diseases and arteriovenous shunting. It should be remembered that cyanosis can arise in poisoning by chemicals or drugs that form methemoglobin and sulphmethemoglobin.
The colour of the skin is important for diagnosis of some heart diseases. Mitral stenosis can be diagnosed by the violet-red colour of the patient's cheeks, mildly cyanotic colour of the lips, nose, and extremities ("facies mitralis").
The skin and visible mucosa of patients with aortal heart diseases are usually pale. Cyanosis in combination with paleness (pallid cyanosis) is characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis of the pulmonary artery. Icteric colour of the sclera and skin is characteristic of grave circulatory insufficiency. The skin of patients with persisting septic endocarditis has a peculiar colour resembling that of coffee with milk (colour " coffee with milk ").
Edema frequently attends heart diseases. If the patient stays out of bed, edema is localized mainly in the malleolus, the dorsal side of the feet, and the shins, where a pressure of fingers leaves slowly leveling impressions. If the patient lies in bed, edema is localized in the sacrolumbar region. If edema is significant, it may extend onto the entire body while the ascitic fluid accumulates in various cavities of the body, such as the pleural cavity (hydrothorax), abdominal cavity (ascites), or in the pericardium (hydropericardium). Generalized edema is called anasarca. The edematous skin, especially the skin of the extremities, is pallid, smooth, and tense. In persistent edema, the skin becomes rigid, its elasticity is lost, and the skin acquires a brown tinge due to diapedesis of erythrocytes from the congested vessels. Linear ruptures may develop in the subcutaneous fat of the abdomen in pronounced edema, which resemble the scars of pregnancy. In order to assess objectively the degree of edema, the patient should be weighed regularly and the amount of liquid taken and excreted should be strictly recorded.
Local edema sometimes develops in cardiovascular pathology. When the superior vena cava is compressed, for example in exudative pericarditis or aneurysm of the aortal arch, the face, neck, and the shoulder girdle can be affected by edema (“the collar of Stokes”). Edema of the affected extremity is complicates thrombophlebitis; ascites develops during thrombosis of the portal vein or the hepatic veins.
The shape of the nails and distal phalanges of the fingers is informative. Drum-stick (Hippocratic) fingers are characteristic of subacute septic endocarditis and some congenital heart diseases.
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Inspection of the heart region and peripheral vessels
Cardiac "humpback" can be seen during inspection of the precordium. This is bulging of the area over the heart, the degree of protrusion depending on the enlargement and hypertrophy of the heart (provided these defects develop in childhood when the chest is liable to changes). General protrusion of the cardiac region and leveling of the costal interspaces are observed in massive effusive pericarditis. The cardiac humpback should be differentiated from deformation of the chest caused by changes in the bones, e.g. in rickets.
In patients with underdeveloped subcutaneous fat and asthenic body build, a limited rhythmic pulsation {the apex beat) can be seen in the fifth interspace, medially of the midclavicular line. This is caused by the perssure of the heart apex against the chest wall. In cardiac pathology, the apex beat may produce a stronger pulsation. If precordial depression is found instead of prominence, the apex beat is said to be negative. It occurs in adhesive pericarditis because of adhesion of the parietal and visceral layers of the pericardium.
The false negative (pseudonegative) apex beat can be observed at asthenics, in a case if the range of an apical beat settles down opposite to a rib. It is a systolic intrusion of a thorax wall to the right and higher of a place of the routine localization of an apex beat that it is inaccurately possible to accept for a negative apical beat.
Pulsation is sometimes observed to the left of the sternal line over a vast area extending to the epigastric region. This is the so-called cardiac beat. It is due to contractions of the enlarged right ventricle; a synchronous pulsation can also be seen in the upper epigastric region (below the xiphoid process).
Pulsation in the region of the heart base is sometimes observed. Pulsation of the aorta can be felt in the second costal interspace to the right of the sternum; it appears either during its strong dilation (aneurysm of the ascending part and of the arch of the aorta; aortic valve incompetence), or in sclerotic affection of the overlying right lung. In rare cases, the aneurysm of the ascending aorta can destroy the ribs and the sternum. Elastic pulsating tumour is then seen. Pulsation in the second and third costal interspace that can be seen by an unaided eye is caused by dilatation of the pulmonary trunk. It occurs in patients with mitral stenosis, marked hypertension in the lesser circulation, patent ductus arteriosus with massive discharge of the blood from the aorta to the pulmonary trunk, and in primary pulmonary hypertension. Pulsation occurring lower, in the third and fourth interspace to the left of the sternum, can be due to the aneurysm of the heart in post-infarction patients.
Inspection of the vessels is very important for assessing the cardiovascular system. Swollen and tortuous arteries, especially temporal arteries, are found in patients with essential hypertension and atherosclerosis; this is the result of their elongation and sclerotic changes. Pulsation of the
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