Clinical History Analysis In Cardiology

Clinical history analysis in Cardiology

As is already known, medical history is a private document that presents legal, ethical, teachers, statistics, medical and clinics characteristics. The data to be collected must be written in adequate, logical, orderly and sequential terms, this must be subdivided into 2 parts the next medical history and the remote medical history, of which the next medical history will be described below.

The next medical history consists of parameters to be correctly filled, among which are the filiation data, the reason for consultation, current history of the disease and interrogation for devices and systems. In relation to the next anamnesis, the data set or information collected during the interrogation will be analyzed. It is the point of interaction between the doctor and the patient. This forces the doctor to identify the characteristics of each of the patients, allows to assess their sensitivity and the level of affectation, which the patient presents and thus subsequently establish a relationship of empathy to improve the quality of care, this will consist ofThree parts (5.6):

Patient identification:

Its objective is to contextualize the patient in a comprehensive way recognizing it by their name, age, the date on which it is made, identification data as the identity document number, telephone to have it, data on academic instruction, typification of blood group, occupation, place of residence and origin among others.

It is important to write down the source of information and reliability, since on many occasions the information is provided by a family member or close friend, all this data conglomerate will allow identifying possible risk factors for many cardiac pathologies that will be ofGreat useful for the subsequent diagnostic orientation (7–9).

Main problem or reason for consultation:

Section of great importance in which a short mention is made of the reason why the patient comes;It must be written with medical terms, for medical-legal reasons. This will be of great help for the easy understanding of it, and thus identify more quick.

Cardiovascular pathology is one of the most frequent reasons in medical consultation since they understand one of the main causes of death in the world. Acute myocardial infarction, strokes and arrhythmias are the diseases that listate the reasons for consultation. It is important to keep control of the cardiac system in order to prevent consequences and complications that cause these pathologies.

Patients over 45 years should frequent their header at least once a year. Similarly, patients with risk factors such as arterial hypertension, high cholesterol levels, or who have chest pain, palpitations or dyspnea should go as soon as possible to medical consultation

In the cardiovascular medical history it is always important to know certain personal history that guides us to a diagnosis in the reason for consultation. Diseases such as diabetes mellitus, pulmonary pathology, obesity, rheumatic fever, angina, claudication or brain diseases. In the same way it is essential to know if the patient smokes or consumes alcohol and because time and in what amount has been doing it.

Current illness

It is a fundamental section of the medical history in which a chronological and detailed writing of the disease that the patient is pursuing at the time of consultation is required. For it, the symptoms and manifestations of disease that he or the patient has been presented should be pointed out, how they have evolved according to time, and in practice, what has happened.

The writing similar to a story in which the events occurred are written, it is a chronological historical document of what the patient occurred in the course of his pathology, either for weeks or months, of which we are interested in that all this isExpose in a direct, understandable language, without abbreviations, faithful to what really happened and, if possible, brief.

In the case of cardiology, it presents great importance in evolution in several diseases since the correct chronological wording importantly guides the possible diagnosis, since several of cardiovascular pathologies have a chronological evolutionary characteristic that must be taken into account. And in the same way if you begin to count on a symptom, in that paragraph it is convenientIt is for the patient (5.7).

The current disease aimed at the study of cardiac pathologies should pay close attention to the signs and symptoms that the patient presents, investigating the most relevant to be able to guide us to make correct diagnostic and therapeutic decisions. (13–15).

Each annoyance that the patient referred to in the reason for consultation and during the story of the current disease must be described by the following characteristics:

1. APPEARING DATE OF START
2. Real start date
3. Start form
4.  Apparent cause
5.  Accompanying symptoms
6.  Evolution
7.  Relationship with medications
8.  Actual state

In cardiology, it is important that current disease has an interrogation for devices or anamnesis by devices, where signs and symptoms can be related, of other systems that are apparently not connected, to the main problem but that can contribute to a diagnosis, alwaysemphasizing those who directly relate cardiovascular pathologies. In this way the organism is considered one and not as independent systems (15,17).

Frequent cardiological symptoms in the clinical presentation of several pathologies force some of them as we have (7,18):

A. Chest pain: Non -traumatic chest pain is one of the most frequent causes of urgent medical consultation, whose management constitutes an important care problem for the following reasons:

• For the magnitude of patients involved: chest pain is one of the most common consultation reasons in an emergency service (5-20% consultations).
• For the importance and difficulties posed by the correct diagnosis before a patient with chest pain. Of patients who come to urgency with chest pain, 50% are oriented to an initial diagnosis of acute coronary syndrome (SCA).

B. Dyspnea: Dyspnea is a doubly subjective clinical symptom, since it is given by what the patient perceives and what the doctor interprets. Therefore, it is appropriate to evaluate the dyspnea and its intensity based on some very validated scale as the widely used of the New York Heart Association (NYHA) in functional degrees (20):

•  Grade I. Dyspnea that appears with efforts superior to those that represents the usual activity of the patient (asymptomatic with habitual activity).
•  Grade II. Dyspnea that appears with the usual activities of the patient.
•  Grade III. Dyspnea that appears with minor efforts from the usual.
•  Grade IV. Rest dyspnea.

C. Palpitations: They are defined as the annoying sensation of the heartbeat. These are interpreted as a frequent symptom in Primary Care (AP) consultations that do not usually translate, severe pathology, since most obey an increase in cardiac contractility in subjects with hypercinetic circulation or a decreased perception threshold. Palpitations with greater clinical relevance, although rare, are those that appear in patients with heart disease in relation to rhythm alterations.

D. Edemas: It is a sign that allows us to see according to the time of the day they occur, clarify its cause, as in the case of evening edema that are usually secondary to right heart failure or peripheral venous insufficiency;Symmetric edemas are typical of right heart failure and appear in the declines;Generalized edemas may be due to right heart failure or liver disease and are frequently accompanied by ascites.

AND. Cough: it is common to find this symptom in the motive of cardiological consultation, which indicates lung, airway and vasculature disease. There may be irritable or spasmodic cough. In cases of heart failure, it is also common to find cough in the patient.

F. SINCOPE: This refers to a sudden loss of consciousness and postural tone, is characterized by being brief and does not need resuscitation. It occurs more frequently in women and can have origin in cases such as blows, lack of oxygen or malnutrition. Which leads to the decrease in blood flow. The patient can refer that before this episode luminous points appeared, blurred vision or sensation of time loss.

G. Cyanosis: bluish skin coloration, mucous membranes and nail beds that are due to concentrations equal to 5 g/dl. This symptom is caused by the lack of oxygen.

Relationship with cardiology.

In cardiology, a medical history based on the correct and chronological writing of the data that has occurred, in addition to physical examination, which allows the evaluating doctor, to interpret and understand the importance data of a cardiological report, the limitations present in the differentSeverity classifications of symptoms and the meaning of anamnesis and exploration in the diagnostic process.

Unfortunately, the clinician can make the error of replacing history and exploration of diagnostic tests that are expensive, uncomfortable and sometimes dangerous for the patient, and useless or counterproductive, for which a correct interrogation is vitally important if they have not beenrequested with a precise and justified indication that is oriented to answer a specific diagnostic question and clinical interest.

The medical history from the cardiovascular point of view must be carried out with an interrogation in which the patient explains and nursing the information concerning and importantly, the same that must be modulated by the clinician to avoid that there is no information without saying or without saying or withoutmention, subsequently, important data such as personal history, which are relevant to study the cardiovascular problem, recognizing that any pathological state that the patient is important is important.

The characteristics of an adequate physical examination to establish the diagnosis in a cardiovascular patient are that it should be as complete as possible, it must always be done in the same way and the same order must always be followed. The physical examination that will be detailed below is one of the most important ways for obtaining information, has the purpose of being eminently practical and tries to leave aside the theoretical considerations that could complicate the analysis of the data of the data of the data of thephysical exploration.

In relation to the current disease, an analysis of the main cardiological symptoms such as dyspnea, chest pain, syncope, palpitations, edema, hemoptysis and fatiguebility must be performed;The patient can present symptoms, which will be assessed by the impact of each of them in their functional capacity and quality of life.

conclusion

Based on the foregoing, it can be determined that the next medical history in the cardiological field has great importance, for which, having a legal, ethical, teacher, statistical, medical and clinical contrast must be taken with the importance that it deserves. In the same way, it should be emphasized that the characteristics of most cardiological diseases take their diagnostic importance from the reason for consultation and the current disease with important clinical data by emphasizing their chronology, without neglecting the filiation data thatThey will allow to assess the presence of risk factors for the diagnosis of present pathology. Which concludes that the next medical history represents a great tool for the diagnostic orientation and correct evaluation of the cardiac patient, as long as the aforementioned characteristics are taken into account.

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