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Cardiology without tears
American
Heart
Journal
September, 1962, Volzwze 64, Number 3
Editorial
Cardiology
without
Geoffrey Bourne, M.D., London, England
tears
F.R.C.P.
T
he rapid and continuous increase in complicated instrumental aids to diagnosis tends, as years go by, to blind the physician to the details of his own clinical technique. There are a number of simple measures which will increase the cardiologist’s efficiency and decrease the patient’s discomfort. The consulting room should be warm and quiet, and not too frighteningly clinical in decoration. An oblique light is an advantage, for when standing in it the patient can be slowly, rotated so as to throw into relief, like the mountains bordering the shadow on the moon, such phenomena as aneurysmal pulsation, systolic recession, and the pulsating collateral arteries of coarctation of the aorta. Easy shading and darkening of the consulting room is necessary if a simple x-ray screening unit forms part of the clinical armamentarium. The examination couch should be broad and tall, to save the physician from unnecessary stooping, and to make easy for the patient that degree of relaxation which helps physical examination and prevents muscular tremor from distorting the electrocardiogram. -1 good breadth for the couch is 30 inches, and a good height is 32 inches. The length should be adequate, ~a!., 6 feet 6 inches, and the adjustable head rnd shoulder raising must be both eas> tnd sufficient. Received
291
for publication
Feb.
21. 1962.
In addition to the usual blankets and pillows the preliminary use of an electric blanket is appreciated in cold weather. History taking, that part of the examination from which the experienced physician can learn most, should never be delegated to a junior or to a nurse. The more personal the examination from start to finish, the greater will be the chance of extracting from a shy patient relevant symptoms, both physical and psychological in nature. Each physician should plan the layout of his own clinical case sheet. It is wise to have this printed. It should be comprehensive, so that even a tired doctor will not for that cause omit some relevant item. -4 good plan is to use a single folder. In addition to personal particulars, such as name, age, and address, there are laid out on the outside page three sections dealing with Past History, Family History, and Present Symptoms. These are subdivided into headings; for example, in the section on Past History are AAcute Rheumatism, Chorea, Scarlet Fever, Syphilis, and Other Diseases. Down the left-hand margin, in order, are cardiac symptoms, such as Dyspnea, Orthopnea, Sighing, Constriction, Pain, etc., and general symptoms, such as Dyspepsia, Bowel Action, Frequency of Micturition, and so on. The center of the page is blank, and here is recorded the detailed case history. Thus,
292
Bourrw
a full clinical picture is completed, symptoms absent being crossed out, and those present, and not otherwise recorded, being ticked or underlined. Useful abbreviations can be added, for instance, Orthopnea 4, underlined, means present and four pillows N needed. Frequency, 3, means micturition normal by day but three times at night. The left inside page, headed Present Condition, deals with the phJ-sical examination. Here again, the important facts are printed, in logical sequence. Above are the headings Dyspnen, Orthopnea, Pallor, etc., and next are Rate, Rhythm, Blood Pressure, State of .k-teries, Veins, and Retinae. Lower down come, Inspection, ,Ipex Beat, Thrills, Heart Sounds, Murmurs, and so on. The sections on lungs and abdominal organs complete that page. On the opposite leaf are “boxes” for notes on the electrocardiogram, on radioscopy. and, finally, beneath one another, spaces for diagnosis, prognosis, and treatment. The completed case sheets are used as folders, each containing letters, hematological and other reports, and copies of the electrocardiograms. They are stored alphabeticall>-, filed at the end of the year, and carried forward annually if the patient is seen at such intervals. IX:xamination. Examination should be made with the patient first standing, and then lying down. The lungs can best be examined when the patient is standing, and in this position the aortic murmurs ma)- be most easily heard. Mitral murmurs are louder in the recumbent and left lateral positions; vasomotor instability and postural hypotension require investigation in both positions. The Master three-step stool, so useful in diagnosing cardiac ischemia, provides also an easy ascent to the higher couch. The dual-purpose stethoscope is best, for high-frequency murmurs, like the aortic diastolic, are most easily heard through the
diaphragm, and the low-frequency mitral diastolic bruits through the bell. The blood pressure is best taken, COIItrar\- to usual practice, \vith the cuff so applied that the rubber tubes run upward toward the shoulder. This leaves the antccubital fossa free for the stethoscope, and places the sphygmomanometer ill a position on, near to, or beside the pillow, and away from the eyes of an inquisitive patient. The most efficient type of ophthalmoscope is that fitted with a 12-volt and 12watt bulb, and run, if necessary, through a transformer, direct from the main suppl!.. Vision of the retina is easier ant1 hettcr than with the batter?. type. ,4 direct-writing electrocardiograph is the most satisfactory for routine clinical work, for the leads can be varied ancl added to according to what is found at the time. Suction electrodes for the limbs, if designed for this USD, save much time a:lcl trouble, hut they n:ed p:riorlic and careful cleaninK. ,A simple x-ray screening unit with \vitle, fixed screen and a tube movable in 110th directions, and with good diaphragms, is an invaluable means of measuring accurately the size of the heart. M’ith the technique developed and used b>- me’ for 30 years, the size of a heart can be accurately measured in a few minutes and followed from year to \-ear. It can he shown to remain stationar>., to have begun to myxedema or enlarge, or, as in treated ligated ductus arteriosus, even to have shrunk. If ;I woolen shawl is hung from clips before the screen, the patient can be spared the clammy kiss of this on the bare skin. The foregoing details of technique are the result of long clinical experience, and have proved both of help to the physician and of comfort to the patient. REFERENCE 1. Bourne, G., and \Vells, B. G.: heart size, Lancet 1:17, 1951.
Measurement
of
Heart
Journal
September, 1962, Volzwze 64, Number 3
Editorial
Cardiology
without
Geoffrey Bourne, M.D., London, England
tears
F.R.C.P.
T
he rapid and continuous increase in complicated instrumental aids to diagnosis tends, as years go by, to blind the physician to the details of his own clinical technique. There are a number of simple measures which will increase the cardiologist’s efficiency and decrease the patient’s discomfort. The consulting room should be warm and quiet, and not too frighteningly clinical in decoration. An oblique light is an advantage, for when standing in it the patient can be slowly, rotated so as to throw into relief, like the mountains bordering the shadow on the moon, such phenomena as aneurysmal pulsation, systolic recession, and the pulsating collateral arteries of coarctation of the aorta. Easy shading and darkening of the consulting room is necessary if a simple x-ray screening unit forms part of the clinical armamentarium. The examination couch should be broad and tall, to save the physician from unnecessary stooping, and to make easy for the patient that degree of relaxation which helps physical examination and prevents muscular tremor from distorting the electrocardiogram. -1 good breadth for the couch is 30 inches, and a good height is 32 inches. The length should be adequate, ~a!., 6 feet 6 inches, and the adjustable head rnd shoulder raising must be both eas> tnd sufficient. Received
291
for publication
Feb.
21. 1962.
In addition to the usual blankets and pillows the preliminary use of an electric blanket is appreciated in cold weather. History taking, that part of the examination from which the experienced physician can learn most, should never be delegated to a junior or to a nurse. The more personal the examination from start to finish, the greater will be the chance of extracting from a shy patient relevant symptoms, both physical and psychological in nature. Each physician should plan the layout of his own clinical case sheet. It is wise to have this printed. It should be comprehensive, so that even a tired doctor will not for that cause omit some relevant item. -4 good plan is to use a single folder. In addition to personal particulars, such as name, age, and address, there are laid out on the outside page three sections dealing with Past History, Family History, and Present Symptoms. These are subdivided into headings; for example, in the section on Past History are AAcute Rheumatism, Chorea, Scarlet Fever, Syphilis, and Other Diseases. Down the left-hand margin, in order, are cardiac symptoms, such as Dyspnea, Orthopnea, Sighing, Constriction, Pain, etc., and general symptoms, such as Dyspepsia, Bowel Action, Frequency of Micturition, and so on. The center of the page is blank, and here is recorded the detailed case history. Thus,
292
Bourrw
a full clinical picture is completed, symptoms absent being crossed out, and those present, and not otherwise recorded, being ticked or underlined. Useful abbreviations can be added, for instance, Orthopnea 4, underlined, means present and four pillows N needed. Frequency, 3, means micturition normal by day but three times at night. The left inside page, headed Present Condition, deals with the phJ-sical examination. Here again, the important facts are printed, in logical sequence. Above are the headings Dyspnen, Orthopnea, Pallor, etc., and next are Rate, Rhythm, Blood Pressure, State of .k-teries, Veins, and Retinae. Lower down come, Inspection, ,Ipex Beat, Thrills, Heart Sounds, Murmurs, and so on. The sections on lungs and abdominal organs complete that page. On the opposite leaf are “boxes” for notes on the electrocardiogram, on radioscopy. and, finally, beneath one another, spaces for diagnosis, prognosis, and treatment. The completed case sheets are used as folders, each containing letters, hematological and other reports, and copies of the electrocardiograms. They are stored alphabeticall>-, filed at the end of the year, and carried forward annually if the patient is seen at such intervals. IX:xamination. Examination should be made with the patient first standing, and then lying down. The lungs can best be examined when the patient is standing, and in this position the aortic murmurs ma)- be most easily heard. Mitral murmurs are louder in the recumbent and left lateral positions; vasomotor instability and postural hypotension require investigation in both positions. The Master three-step stool, so useful in diagnosing cardiac ischemia, provides also an easy ascent to the higher couch. The dual-purpose stethoscope is best, for high-frequency murmurs, like the aortic diastolic, are most easily heard through the
diaphragm, and the low-frequency mitral diastolic bruits through the bell. The blood pressure is best taken, COIItrar\- to usual practice, \vith the cuff so applied that the rubber tubes run upward toward the shoulder. This leaves the antccubital fossa free for the stethoscope, and places the sphygmomanometer ill a position on, near to, or beside the pillow, and away from the eyes of an inquisitive patient. The most efficient type of ophthalmoscope is that fitted with a 12-volt and 12watt bulb, and run, if necessary, through a transformer, direct from the main suppl!.. Vision of the retina is easier ant1 hettcr than with the batter?. type. ,4 direct-writing electrocardiograph is the most satisfactory for routine clinical work, for the leads can be varied ancl added to according to what is found at the time. Suction electrodes for the limbs, if designed for this USD, save much time a:lcl trouble, hut they n:ed p:riorlic and careful cleaninK. ,A simple x-ray screening unit with \vitle, fixed screen and a tube movable in 110th directions, and with good diaphragms, is an invaluable means of measuring accurately the size of the heart. M’ith the technique developed and used b>- me’ for 30 years, the size of a heart can be accurately measured in a few minutes and followed from year to \-ear. It can he shown to remain stationar>., to have begun to myxedema or enlarge, or, as in treated ligated ductus arteriosus, even to have shrunk. If ;I woolen shawl is hung from clips before the screen, the patient can be spared the clammy kiss of this on the bare skin. The foregoing details of technique are the result of long clinical experience, and have proved both of help to the physician and of comfort to the patient. REFERENCE 1. Bourne, G., and \Vells, B. G.: heart size, Lancet 1:17, 1951.
Measurement
of