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Clinical cardiology p.1

Table of contents
Clinical cardiology p.1
Anamnesis
Anamnesis of this disease
Heartbeat
Pains in heart
Stenocardia
Alternative stenocardia
Anginous pain at a myocardial infarction
Breath disturbances
Cheyn-Stokes's breath
Cough of a cordial origin
Syncope
Cardiac faint
Other complaints
Research of the patient
Central and peripheral types of cyanosis
Systematic research of the head and neck
Systematic research of a thorax

Prof. Dr. Vratislav Yonash
Clinical cardiology
PRAGUE 1966

INTRODUCTION
The diagnosis of a heart trouble is responsible, and is frequent and filling with misgivings, the decision of the doctor. Disturbances of functions of bodies of blood circulation often involve adverse effects for an organism, and statistical data on mortality show that heart trouble and vessels in all civilized countries represent the most frequent cause of death of patients at mature age. Besides, in society the classical wrong opinion on incurability and hopelessness of a heart disease still keeps. It is fair that only the part of cordial disturbances completely recovers, but it is fair also what honor in all cases of not too far come morbid condition the patient can provide the effective help. In many cases it is possible to slow down at least disease, and sometimes to detain it for some time or even completely to stop. Nevertheless, it is difficult to find a disease which would cause so much fear in laymans, how exactly heart troubles. The fear of a sudden cardiac death so took roots that it is not easy to eliminate it. Any negative statement of the doctor about a condition of heart and blood circulation which is improvidently made by the doctor in the presence of the patient causes adverse representations in more sensitive persons. Actually, however, the sudden, unexpected cordial death happens not often, except for acute insufficiency of coronal vessels. Acute early decline of activity of sore heart similarly meets much less than it often think. The vast majority of organic heart troubles progresses rather slowly and often the long time without subjective signs proceeds. Quite often the death occurs for other reason, but not as a result of a heart trouble. By the corresponding treatment usually it is possible to distance considerably completing, already irreversible cardiac disturbance though at permanent, rather heavy injury of heart this danger, as a rule, cannot be prevented forever. A large number of patients despite considerable, as acquired, and inborn organic changes of the device of blood circulation, for many years and even lead decades full-fledged life, is frequent without considerable indispositions. In optimum cases there can come absolute clinical recovery. Besides, many disturbances of heart in essence happen favorable, do not cause predictive fears and are compatible to long life and total activity of the victim.
The diagnosis of a heart trouble should be stated before the patient only in the presence of undoubted signs of injury of heart which, remaining often hidden from the patient, according to clinical experience happens resistant and at the same time so heavy that breaks cordial activity in such degree that heart carries out the task set for it at the expense of reserve forces. Under such circumstances it is necessary to reckon that an inappropriate exercise stress, the accompanying infection, deterioration in food of a cardiac muscle owing to atherosclerotic changes of coronal arteries and rather advanced age, and most often gradual and natural development of own changes of heart causing disturbance of cordial activity will cause dynamic or coronary heart failure, or joint insufficiency of both types sooner or later.
It is indisputable that earlier recognition of damage of heart is decisive for destiny of the patient. It is one of the major tasks at regular medical examinations of children of school age and at periodic medical examinations of adult persons. The main mistake consists that many persons see a doctor when they are already seriously sick. There are no doubts that in many cases it would be possible to prevent emergence of damage by the regular control examinations of a state of health conducted at least once a year, even in the absence of strong indications of an illness both, of course, especially and, certainly, that is more often at emergence of suspicious indispositions or at emergence of circumstances under which it is necessary to reckon with a possibility of damage of the device of blood circulation. There is a large number of the warning signs testimonial of disturbance of cordial activity, such as, emergence of an asthma at a physical tension, an unusual breakdown and dizziness after very short physical activity, inexplicable disturbances of digestion, hypostases of the lower extremities, etc. These signs should not touch heart and can be caused by a disease of other body. Some of number of the above-stated indispositions can occur also at persons with normal objective data and their value can be strongly exaggerated by the layman. Despite it it is recommended to see a doctor as it can be display of very serious disease. On the other hand, it is indisputable that many persons having an organic disease of the device of blood circulation for many years do not test indispositions. However it is very important to distinguish disturbance and to give the correct assessment of a condition of heart during this period when still it is possible to achieve success by purpose of the preventive actions directed to a distance of heart failure.
All patients having a heart trouble should settle the vital mode reasonablly. To limit to some of them rather only a little physical activity, and others should recommend a constant sedentary life. In spite of the fact that the patient with an organic heart trouble in most cases cannot promise treatment, nevertheless many of them can be assured that at the correct vital mode and the corresponding treatment they for long time can keep vital activity. Unfortunately many warm-hearted patients get to the specialist only after emergence of strong indications of heart failure. Nevertheless even in these rather adverse cases the difference between the correct and wrong doctor's advice can mean several years of life.
To a regret, among doctors during their practical work big uncertainty in recognition, an assessment and treatment of heart troubles so too often there are mistakes is noted. The conscientious practical doctor in the questions concerning activity of the device of blood circulation quite often trusts the knowledge much less, than in other industries of internal diseases. First of all it is necessary to know limits in which the data received at clinical and laboratory trials of bodies of the device of blood circulation are considered as normal. Further it is required to master the knowledge serving as the reliable management for statement of the diagnosis of cardiovascular disturbances and it is correct to own medical indications. From medical practice several wrong views of major importance still do not disappear. First of all it concerns representation that any of so-called main cordial complaints, such as heartbeat, the complicated breath, pains in heart, and also some objective signs from heart, for example, noise, inevitably testify to a heart trouble, and at normal physical, skiaskopichesky and electrocardiographic data, on the contrary, the doctor is inclined to consider that heart is healthy. Will consider as a mistake similarly an irregular cordial rhythm a reliable sign of organic damage of a cardiac muscle and, on the contrary, not accelerated and regular cordial activity does not allow to come to conclusion yet that the cardiac muscle is really not broken. In practical work the wrong diagnosis of an organic heart trouble is quite often made and the wrong treatment is appointed. Thereby the way of life of the affected person is excessively broken and there is a number of the indispositions following from disturbance of nervous and mental balance.
All doctors should understand damage which can be caused by a lack of knowledge and clinical experience, or improvidence at the statement of the conclusion about cordial activity and in general about a condition of the blood circulatory system. The doctor has to be the good psychologist and reckon that even the person with resistant character can sometimes lose balance, having learned that his heart not as it should be. Before the patient it is necessary to be careful of such expressions as stenocardia, heart attack, coronarothrombosis, arteriosclerosis, blood supertension which among laymans reasonably have bad reputation, and whenever possible, in general not to use them. It is desirable to abstain from excessive notes on various deviations established on heart, and from all intimidating statements about a condition of the device of blood circulation. It is the best of all to speak about results of research in general, emphasizing, whenever possible, favorable circumstances. In this case the doctor is faced by an important task first of all to calm and encourage the patient and to get his trust. Only after careful accounting of a psychological state it is recommended to acquaint gradually and carefully the patient in more detail with his illness. However it is necessary to explain true position painful to some reliable person from his direct environment and to acquaint this person with necessary actions. How carefully it is necessary to treat the patient shows the well-known experience noted at those patients who up to that moment when they learned from the doctor that they have a heart trouble, or had no complaints, or only uncertain signs. Such patients quite often have afterwards constantly increasing indispositions and the patient begins to suffer much more from fear and fears about the heart, than from own heart trouble. If it is possible to calm the patient, then there can come the simplification in spite of the fact that objective these researches of heart are left without changes. All value of the correct recognition of essence of pathological process, careful attitude and provident conversation with the patient best of all become clear at functional disturbances of heart. Disability is caused in many patients with a neurocirculatory adynamy by the wrong definition of a condition of heart and fear which arose owing to rash behavior of the doctor.
The special attention is deserved by sudden disturbances of balance of circulation to which some of the most critical situations able belong to be followed by direct danger to the patient's life. At any critical state which could be a cardiovascular origin a lot of things depend on the fast analysis of all clinical picture. Extreme importance is gained by whenever possible instant recognition of true essence of an attack as early purpose of the corresponding treatment in certain cases can save the patient's life. It is necessary that each practical doctor was completely acquainted with a symptomatology of the critical states demanding the special help. He has to know action, a dosage, indications and contraindications to use of new therapeutic actions and medicines. Fortunately, many of so-called heart attacks in essence happen favorable and can spontaneously disappear. In many cases it is enough to calm the patient and to appoint simple means. Uncertainty of the doctor or his daredevil acts can cause extensive damage. Mainly it is necessary to distinguish sudden cardiovascular disturbances from attacks of other origin and decline of cordial activity from primary acute insufficiency of peripheric circulation.
In practice the doctor meets several main problems concerning a condition of heart. In the presence in the anamnesis of signs which could testify to a heart trouble it is necessary to resolve an issue whether the heart disease is the reason of indispositions really. It is necessary to take into account that persons with sore heart can also have such disturbances, such as, bilious colic, a perforation of the ulcer of a stomach or duodenum, internal bleeding, a syncope of a brain origin, etc. The further important task consists in the correct assessment of a condition of the device of blood circulation at the patient suffering from one of those diseases which often are followed by primary or secondary damage of heart or peripheric circulation. The rheumatic illness, the postponed syphilis, dysfunction of a thyroid gland, some chronic defeats of respiratory bodies and similar states can be an example. At detection of symptoms of a heart trouble it is necessary to decide in what functional state there is heart as treatment essentially depends on whether disturbance of cordial activity is compensated or there are symptoms of heart failure.
The methods applied at research of the device of blood circulation can be divided into 4 groups:

  1. Inquiry of the patient, or the anamnesis serving for clarification of complaints of the patient and identification of the etiological and various other factors relating to disturbances of heart;
  2. simple physical research which has to be careful and whenever possible exhaustive;
  3. auxiliary laboratory researches, such as, skiaskopiya and skiagrafiya, electrocardiography, oftalmoskopiya, biochemical and functional research;
  4. surgical "trial" or "diagnostic" interventions and bioptichesky research.

Unfortunately, there are no reliable subjective signs which would be pathognomonic, absolutely characteristic of a heart trouble. Certain precursory symptoms of cordial disturbance, as a matter of fact, are absent. The main complaints of warm-hearted patients, such as, short wind, pains in heart, cough, represent rather late phenomena and usually testify already to insufficiency of cardiac performance. The reason of the majority of indispositions is not in heart, and either in lungs, or in some other body suffering for the second time as a result of frustration of dynamic, delivery cardiac performance. Therefore the above-stated signs follow from the broken function of heart and can be combined — often, however, are not combined — with structural changes of heart. Besides, the data obtained at poll of the patient, as a rule, are purely subjective feelings and for an assessment of their importance there are no well-tried objective remedies. In view of the fact that emergence and insistency of signs depend also on degree of a susceptibility of the central nervous system, the same morbid condition can cause pains of different intensity in different patients. It is very important to know and be able to give the correct assessment to all factors causing individual variability of clinical manifestations of cardiovascular defeats. Besides, it is necessary to reckon that the same signs which occur at serdechnobolny can be caused by primary pathological process in other bodies, but not in heart. It is also impossible to forget that the heart trouble a long time can proceed without indispositions, even at Far come organic changes. In such cases it is necessary to rely on results of physical and laboratory researches. Therefore, it is impossible to hope only for the anamnesis.
Fortunately, in most cases for identification of the objective signs allowing to distinguish a heart trouble it is enough to resort to research at the patient's bed, using usual clinical methods. Therefore certainly it is necessary to master the main clinical methods of research proceeding from use of the simple natural sense bodys of the investigating person which are not armed with more or less difficult devices. The main physical methods of research became the integral component of medical inspection and their technical performance was consolidated by clinical experience. It is necessary to know, however, limits of reliability of these clinical methods of research. It is undoubted that only some physical signs certainly demonstrate existence of an organic heart trouble. Here belong: 1. indisputable signs of increase in heart, 2. diastolic "cat's purring", diastolic noise and cantering rhythm, 3. pericardial rub, 4. some disturbances of a rhythm, such as atrial fibrillation, atrial flutter, and various types of an atrioventricular block of heart.
Necessary main premises of clinical trial and useful grant for reasonable individual treatment is carefully made case history. It has to contain all important data and changes found by means of the above-stated diagnostic methods, further records about rather important changes and incidents established during an illness about results of researches and also record about a way of treatment and the achieved results. Experience of the doctor depends not on the number of the inspected and treated patients, and on care of studying and research of certain patients and on extent of use of these supervision for enrichment of his knowledge. The doctor deepens the practical knowledge mainly by long continuous exercise and personal experience. Profession of a physician cannot be acquired according to books. Though book knowledge represents necessary premises, however, the fact that the doctor sees the patient is decisive, speaks with him, investigates him and watches disease in each separate case. It is necessary to emphasize that the majority of mistakes at recognition and treatment of heart troubles and diseases in general is caused not by absence of knowledge, but haste and the superficial relation to business. Unfortunately the doctor in operating time often has time so he is forced to be guided rather by an instinct, than knowledge. Doctors have to aim to eliminate this rough defect and it depends only on them as only careful research of the patient can reliably lead to the purpose.



 
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