Medical history and physical examination for coronary artery disease

Examination Overview

A medical history and physical examination are always a part of evaluating a person who has symptoms of chest pain or risk factors for heart disease.

During the medical history, the doctor will focus on areas such as:

• Chest pain or other symptoms of heart disease. Your doctor will ask you to describe your pain. Also, he or she will want to know where the pain starts and if it spreads to other parts of your body. Your doctor will also ask when the pain happens. Tell your doctor about other symptoms, such as nausea, vomiting, shortness of breath, dizziness, fainting, rapid heartbeat, irregular heartbeat, or "skipped" heartbeat, along with your chest pain.
• Other symptoms of coronary artery disease, such as fatigue, irregular or rapid heartbeats, swelling, shortness of breath, coughing, or difficulty breathing when lying down.
• Personal health history. Your doctor will ask questions about your health and lifestyle. He or she will ask about your cholesterol levels, blood pressure, exercise habits, stress level, and other areas of your life. Tell your doctor if you smoke, or have diabetes, or any other health problems.
• Family medical history. Your doctor will want to know if your parents, brothers and sisters, and children have or had heart disease, especially at an early age. Tell your doctor if you have a family history of heart attack, heart failure, abnormal heart rhythms, sudden death, diabetes, high cholesterol, and high blood pressure.

A complete physical examination will also be done. This may include:

• A blood pressure check.
• An examination for fatty deposits (xanthomas) under the skin.
• A general assessment of blood circulation. Circulation can be evaluated by checking skin colour, fingernails and toenails, and pulses in several locations, including the neck, wrist, and feet.
• A funduscopic examination of the back of the eye (retina). Changes in the blood vessels in the retina give clues to the presence and severity of high blood pressure or diabetes.
• An examination of the blood vessels of the neck by looking at them and by listening to blood flow using a stethoscope.
  • Bulging or swollen neck veins may be a sign of heart failure.
  • Changes in how the blood sounds as it flows through a narrowed artery can be heard when listening to the arteries in the neck (carotid arteries).
• Listening to the heart with a stethoscope for heart murmurs and extra heart sounds.
• Listening to the lungs for abnormal breath sounds. Soft crackling sounds (crepitations or rales) may be a sign that heart failure has caused fluid to build up in the lungs.
• An examination of the abdomen. Using a stethoscope, the doctor will listen to blood flow in the abdomen. Changes in the sounds of blood flow (bruits) may indicate a narrowed blood vessel in the abdomen. This is a sign of hardening of the arteries (atherosclerosis) in the large blood vessels that run through the abdomen.
• A check for swelling in the feet and legs (a sign of heart failure). Fluid buildup in the legs causes swelling (edema) and may be a sign of heart failure. To assess swelling in the legs, the doctor will press down on the skin over the lower leg bone. Edema is present if the pressure leaves a dent in the skin.

Why It Is Done

The combination of medical history, physical examination, and electrocardiography (ECG or EKG) is used to evaluate most people who have chest pain that does not have a clear cause. This combination of tests also is used to evaluate people with chest pain that appears to be stable angina or those who are at risk for heart disease.

Results

A medical history and physical examination may provide the following results.

Normal

A normal medical history and physical examination do not always mean that no further tests are needed.

The following are normal results:

• No risk factors for heart disease based on history
• Normal heartbeat: strong heartbeat, regular rhythm, less than 100 beats per minute but more than 50 beats per minute
• Normal blood pressure. Systolic blood pressure is less than 140 mm Hg; diastolic blood pressure is less than 90 mm Hg.
• No signs of hardening of the arteries. All pulses are strong and equal; no abnormal sounds (bruits) are heard when listening to blood flow through blood vessels.
• No signs of an enlarged heart
• No new heart murmurs are heard.
• No signs of heart failure (swelling in the legs or feet, lung congestion)

Abnormal

An abnormal medical history reveals risk factors for heart disease. An abnormal medical history, physical examination, or EKG may lead to further testing, depending on how likely it is that you have heart disease. The following are abnormal results:

• History of chest pain that occurs predictably with activity and is relieved by rest
• Abnormal heart rate or rhythm
• Abnormally high or low blood pressure
• Signs of atherosclerosis (diminished or unequal pulses in the arms or legs, abnormal sounds heard when listening to blood flow through blood vessels)
• New or changed heart murmur
• Enlarged heart
• Signs of heart failure (bulging neck veins, extra heart sounds, fluid in the lungs, fluid buildup in the abdomen, enlarged liver, or swelling in the legs and feet)
• Medical history reveals two or more risk factors for heart disease.

The decision to do further testing based on the medical history and physical examination will depend on:

• The severity of the signs of heart disease.
• How likely it is that the findings are related to heart disease.
• How likely it is that the course of heart disease can be changed based on the person's age and other factors.

An EKG usually is done whenever a heart-related problem is suspected. If the medical history and physical examination indicate that coronary artery disease is present, other tests, such as the stress echocardiography or stress thallium test, may be used.

If the medical history and physical examination suggest that the cause of chest pain is not related to the heart (such as a stomach ulcer or gastroesophageal reflux disease), other testing may be done to evaluate for other conditions. For information on the symptoms of these conditions, see the topics Peptic Ulcer and Gastroesophageal Reflux Disease (GERD).

What To Think About

After the medical history and physical examination, the doctor may have a better idea about whether the symptoms are caused by coronary artery disease and how severe it may be. Risk factors are an important part of deciding what further testing is needed. The history and physical examination help to guide further decisions about testing and treatment. Extensive testing is not always necessary to diagnose coronary artery disease.

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Author:	Douglas Dana Robin Parks, MS	Last Updated: September 21, 2007
Medical Review:	Anne C. Poinier, MD - Internal Medicine Caroline S. Rhoads, MD - Internal Medicine Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology Robert A. Kloner, MD, PhD - Cardiology Ruth Schneider, MPH, RD - Diet and Nutrition
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