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Medical History and Physical Examination

by Michael J. Shea, MD

Doctors first ask about symptoms. Chest pain, shortness of breath, palpitations, and swelling in the legs, ankles, and feet or abdomen suggest a heart disorder. Other, more general symptoms, such as fever, weakness, fatigue, lack of appetite, and a general feeling of illness or discomfort (malaise), may suggest a heart disorder. Pain, numbness, or muscle cramps in a leg may suggest peripheral arterial disease, which affects the arteries of the arms, legs, and trunk (except those supplying the heart).

Next, doctors ask about

  • Past infections

  • Previous exposure to chemicals

  • Use of drugs, nonprescription naturopathic agents, illicit drugs, alcohol, and tobacco

  • Home and work environments

  • Recreational activity

  • Family history of disorders that may affect the heart or blood vessels

During the physical examination, doctors note the person's weight and overall appearance. The blood pressure and body temperature are also checked. Doctors look for paleness (pallor), sweating, or drowsiness, which may be subtle indicators of heart disorders. The person's general mood and feeling of well-being, which also may be affected by heart disorders, are noted.

Skin color is assessed because pallor or a bluish or purplish coloration (cyanosis) may indicate anemia or inadequate blood flow. These findings may indicate that the skin is not receiving enough oxygen from the blood because of a lung disorder, heart failure, or various circulatory problems.

The pulse in arteries in the neck, beneath the arms, at the elbows and wrists, in the abdomen, in the groin, at the knees, and in the ankles and feet is felt to assess whether blood flow is adequate and equal on both sides of the body. An abnormality may suggest a heart or blood vessel disorder.

The veins in the neck are inspected while the person is lying down with the upper part of the body elevated at a 45° angle. These veins are inspected because they are directly connected to the right atrium (the upper chamber of the heart that receives oxygen-depleted blood from the body) and thus give an indication of the volume and pressure of blood entering the right side of the heart.

Doctors press the skin over the ankles and legs and sometimes over the lower back to check for fluid accumulation (edema) in the tissues beneath the skin.

The light-sensitive membrane on the inner surface of the eyes (retina) is the only place doctors can directly view veins and arteries. Doctors use an ophthalmoscope (see What Is an Ophthalmoscope?) to view the blood vessels of the retina. Visible abnormalities in the retina are common among people with high blood pressure, diabetes, arteriosclerosis, and bacterial infections of the heart valves.

Doctors observe the chest to determine whether the breathing rate and movements are normal. By tapping (percussing) the chest with the fingers, doctors can determine if the lungs are filled with air, which is normal, or if they contain fluid, which is abnormal. Percussion also helps determine whether the sac that envelops the heart (pericardium) or the layers of membranes covering the lungs (pleura) contain fluid. Using a stethoscope, doctors also listen to the breathing sounds to determine whether airflow is normal or obstructed and whether the lungs contain fluid as a result of heart failure.

By placing a hand on the person's chest, doctors can feel (palpate) where the heartbeat is strongest and thus determine heart size. The quality and force of contractions during each heartbeat can also be determined. Sometimes abnormal, turbulent blood flow within vessels or between heart chambers causes a vibration (called a thrill) that can be felt with the fingertips or palm.

By listening to (auscultating) the heart with a stethoscope, doctors can hear the distinctive sounds caused by the opening and closing of the heart valves. Abnormalities of the valves and heart structures create turbulent blood flow that causes characteristic sounds called murmurs. Turbulent blood flow typically occurs as blood moves through narrowed or leaking valves. However, not all heart disorders cause murmurs, and not all murmurs indicate a heart disorder. For example, pregnant women usually have heart murmurs because of a normal increase in blood flow. Harmless heart murmurs also are common among infants and children because of the rapid flow of blood through their heart’s smaller structure. As blood vessel walls, valves, and other tissues gradually stiffen in older people, blood may flow turbulently, even when no serious heart disorder is present. Also, doctors may hear clicks and snaps when an abnormal valve opens. A gallop rhythm (a sound resembling that of a galloping horse), due to one or two extra heart sounds, is often heard in people who have heart failure.

When heard through a stethoscope, turbulent blood flow produces a murmur as blood tumbles over an abnormal heart valve. A similar sound called a bruit is heard as blood goes through a narrowed or irregular artery. A bruit indicates that atherosclerosis, which is a major risk factor for TIAs, is present.

Turbulent Blood Flow

By placing the stethoscope over arteries and veins elsewhere in the body, doctors can listen for sounds of turbulent blood flow (bruits). Bruits may be caused by narrowing of blood vessels, increased blood flow, or an abnormal connection between an artery and a vein (arteriovenous fistula).

Doctors feel the abdomen to determine if the liver is enlarged. Enlargement may indicate that blood is pooled in the major veins leading to the heart. Swelling of the abdomen due to fluid accumulation may indicate heart failure. By pressing gently on the abdomen, the doctor checks the pulse and determines the width of the abdominal aorta.

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