Chest
Volume 114, Issue 3, September 1998, Pages 793-795
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Quality of History Taking in Patients With Aortic Dissection

https://doi.org/10.1378/chest.114.3.793Get rights and content

Study objectives: Aortic dissection generally is an acute catastrophe. Rapid diagnosis is critical. We hypothesized that the quality of history taking contributes to the accuracy of diagnosis in patients with dissection.

Design: Retrospective chart review of 83 patients, whose diagnosis of aortic dissection was confirmed by autopsy, surgery, CT scan, echocardiogram, or angiogram. The quality of the initial history was reviewed using predetermined criteria. The physicians' initial clinical impressions were recorded.

Results: The examining physician correctly suspected aortic dissection after the initial clinical evaluation in 54 of 83 patients (65%). Only 33 of 78 patients with symptoms (42%) were asked about the quality, location, and onset of their pain, the three descriptors identified a priori as important. In 19 patients (24%), only zero or one descriptor was recorded. When all three questions were asked, dissection was suspected in 30 of 33 patients (91%); when zero, one, or two questions were asked, dissection was suspected in 22 of 45 patients (49%).

Conclusion: Despite important advances in diagnostic imaging, accurate diagnosis of aortic dissection requires an accurate history. In our series, the quality of initial history was associated with the accuracy of the initial clinical impression in patients with aortic dissection.

(CHEST 1998; 114:793–795)

Section snippets

MATERIALS AND METHODS

We reviewed the medical records of 83 patients diagnosed as having aortic dissection between January 1985 and December 1994. The diagnosis of dissection was confirmed by autopsy in 4 patients, by surgery in 38 patients or by CT scan, echocardiogram and/or angiogram in 41 patients.

The history obtained at the initial clinical evaluation was reviewed for inquiries concerning the following three descriptions of pain: quality, rather than just presence; radiation; and sudden intensity at onset. A

Demographics and Predisposing Factors

More women than men were affected with average age near 60 years in both proximal and distal dissections (Table 1). Hypertension was the most common risk factor present in most patients with both proximal and distal dissection. Connective tissue disease, including Marfan's syndrome, trauma, bicuspid aortic valve, and prior surgery to the aorta were more common in patients with proximal dissection.

Methods of Diagnosis

After completion of the initial history, physical examination, ECG, and chest radiograph, the

DISCUSSION

Aortic dissection has a distinctive clinical presentation. It is a catastrophic disorder with rapid death if untreated. Diagnosis can often be made readily with noninvasive techniques. Treatment is of proven benefit. Therefore, it is critical that the initial history be of sufficient quality to raise suspicion of dissection.

Prior to the advent of therapy for dissection and prior to the development of excellent noninvasive modalities for diagnosis, clinicians routinely took meticulous histories.

CONCLUSION

Despite important advances in diagnostic imaging for aortic dissection, accurate diagnosis still requires an accurate history. The selection of tests, their interpretation, and subsequent therapy necessarily rely on the initial clinical suspicion generated in large part by a carefully elicited history.

REFERENCES (15)

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Manuscript received August 28, 1997; revision accepted February 19, 1998.

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