Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine 9780128176160, 0128176164

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Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine

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Integrative Cardiovascular Chinese Medicine Series

Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine Volume 5

Anika Niambi Al-Shura, BSc, MSOM, PhD Niambi Wellness Institute Integrative Cardiovascular Chinese Medicine St. Petersburg, Florida, USA

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright Ó 2020 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-0-12-817616-0 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Stacy Masucci Acquisition Editor: Katie Chan Editorial Project Manager: Tracy Tufaga Production Project Manager: Poulouse Joseph Cover Designer: Matthew Limbert Typeset by TNQ Technologies

In Memory This textbook is dedicated in memory of my late parents. To Mary A Cummings (1954e2006) who passed away of heart failure and other related diseases, I am continuing to keep my promise of finding out what was wrong with you and what could have been done to prevent some of them. To my father AbdurRahman Qurban Al-Shura (1949e80), I followed what you advised me to do in life, and taught me to always find a way to make it happen.

The writing of this textbook is dedicated to my son, Khaleel Shakeer Ryland, and his son, my grandson Khaleem Qurban Ryland. Your ancestors motivated me to find important solutions that may help some people in this world be relieved of suffering. May this legacy inspire and guide you to do the same in this life and to pass our ways on to future descendants.

Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Dr. Al-Shura biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Section I Intake and narrative Chapter 1 Intake techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Practitioner bedside manner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Collecting information: cardiovascular patient intake form . . . . . . . . . . . . . . 6 Managing patient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 2 Patient narrative techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Patient preparation for clinical visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Talking to the cardiologist and traditional Chinese medicine specialist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Important logs to consider when a patient creates or modifies an ADL diary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Section II Inquiry and examination Chapter 3 Inquiry and examination techniques . . . . . . . . . . . . . . . . . . . . . . . . . 23 Interviewing patients and reporting useful information . . . . . . . . . . . . . . . . 23 Recording information from the patient diary . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Section III Disorders, treatment principles & plans Chapter 4 Chest pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Part 1: Direct symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Part 2: Inquiry and examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5 Dyspnea and orthopnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Orthopnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Inquiry and examination of dyspnea and orthopnea in western medicine and traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Chapter 6 Heart palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Inquiry and examination of palpitations in Western medicine and traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 EKG: detecting evidence of arrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Diagnosing the root cause of heart palpitations . . . . . . . . . . . . . . . . . . . . . . . . 61 Nutritional supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Chapter 7 Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Cardiac concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Cerebral concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Inquiry and examination of syncope in western medicine and traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Diagnosing factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

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Chapter 8 Edema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Renal factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Cardiopulmonary factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Hepatic factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Inquiry and examination in western medicine and traditional Chinese medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter 9 Claudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Inquiry and examination of claudication in western medicine and traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

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Preface

The Development, Promotion, and Ongoing Research of Integrative Cardiovascular Chinese Medicine Integrative Cardiovascular Chinese Medicine (ICCM) is an area of medical study, research, and education with basic medical sciences, theories, and practices. It was created by Dr. Anika Niambi Al-Shura in 2014 as part of her doctorate degree. Cardiology in Chinese Medicine first became an interest during her early years of study in Chinese hospitals in China in 2004e06. At the time Dr. Al-Shura got a great opportunity to travel to China to work and study. It had dawned on her that before her father died in 1980, he predicted that she would study sciences and travel east to do something important. Dr. Al-Shura decided that she could search for ways to improve on her skills and master’s degree in Oriental Medicine education to help her mother, Mary, suffering from advancing cardiovascular diseases. Before important revelations in medicine and health care became understood in her mission, Mary passed away in her early 50s in 2006. Dr. Al-Shura continued her study and went on to hospital research in China between 2006 and 2014. She was recycling what her father had predicted directly to her word for word, realizing it may have been bigger than finding ways to only help her mother. Realizing that her father’s prediction seemed to be coming true, she used this period to learn and think about how she could have been able to care for Mary and possibly relieved or cured certain cardiovascular disorders had she survived. It became apparent that Mary’s ignored genetic predispositions, lifestyle, and practitioner racial/cultural profiling assumptions about prescribing, maintaining, and prolonging pharmaceutical drug use, and without access to gold star therapies even though the means to afford such therapies were available, were contributors to her advancing condition. Consideration and empathy for these factors from her health-care team and a careful analysis of the condition early on, the method of combining herbal therapy, nutrition, and pharmaceutical drug therapy, had this method been available at the time, may have had a positive impact. Today, Dr. Al-Shura’s work in developing her subject of ICCM is partially in memory of her mother who lived before the dawning of the integrative medicine era. Health-care practitioners, cardiovascular patients, and the public who study from the textbooks in the Integrative Cardiovascular Chinese Medicine series should note the basic medical sciences, theories, and practices which revolve throughout the textbooks, making it necessary to read them first in order then randomly several times. The reader who studies among the integrative cardiovascular Chinese medicine series embarks on a leg of the life

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journey, discovering what small and significant accomplishments one may achieve in their own well-being. Themes which can be found in the textbooks throughout the series are as follows: 1. ICCM acknowledges and integrates the history of the ancient and modern medicine perspectives from cultures around the world. Science and medicine was shared and preserved on some continents while being destroyed or lost on others. 2. ICCM establishes the belief that the human body can be explained through static scientific explanations of anatomy and physiological mechanisms and actions and through dynamic perspectives which brings people together in common and makes each person unique. Personalizing medicine can put analysis and insight into focus and tailor treatment more effectively. 3. ICCM acknowledges that patient autonomy and responsibility is a necessary and primary factor in health and well-being. Patients must enter the health care arena with a clear intention to heal and a detailed narrative that assists in that purpose. They must partner with providers in compliance with what is required to assist health restoration. 4. ICCM establishes the belief in practitioner empathy and the ability to listen, teach, and guide patients. Also, the ability to discern when utilizing one or more than one system of medicine to help a patient who also helps themselves heal. 5. ICCM considers the etiology of diseases as dynamic as the constant changes in modern and urban life. 6. ICCM considers genetic information as crucial as the patient family and personal history. Physical exam and diagnostic methods should involve routine practices of more than one system of medicine. 7. ICCM considers genetic information, innate and seasonal adaptions in body constitution are as crucial as the patient family and personal history. Certain key factors in a patient’s health-care profile make a significant difference when choosing a herbal formula, nutritional supplement, and pharmaceutical drugs singly or in combination in therapy. 8. ICCM establishes the belief that knowledge of herbal constituents in herbs that combine to swiftly restore health are used to make up a single formula or combination of formulations in acute, recovering, and preventive care in cardiology. Knowledge of nutritional deficiencies associated with cardiovascular symptoms helps in dietary planning over a short treatment course or a permanent lifestyle in acute, chronic, recovering, and preventive stages of care. Use of pharmaceutical drugs can assist with acute and chronic conditions where herbs and nutritional intervention is ineffective or the condition has reached a stage of no return to health restoration. Lifestyle modification that helps avoid preventable cardiovascular disorders leads to personal well-being. Chapters in each textbook involve the latest published research from around the world that identifies agreement of theories of principles of ICCM with ongoing research and established protocols of medical science. On of the purposes of exposure of ICCM is to encourage practitioners and patient to adopt our principles when applicable to improve health outcomes and to encourage medical researchers to study our principles and publish

Preface

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results in internationally recognized journals. I welcome your constructive comments, suggestions, and ideas which may improve or enhance content for future editions and courses offered for learners. Please write to: Dr. Anika Niambi Al-Shura St. Petersburg, FL, USA

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Dr. Al-Shura biography Dr. Anika Niambi Al-Shura is originally from Louisville, Ky, USA. She has one son, one grandson, and resides in Kentucky and Florida, USA. She enjoys cultivating medicinal plants and formulating medicinal herb recipes, soapmaking, fine art, travelling internationally to meet people for learning new cultures and ways of living, mountain hiking, and relaxing on the beach near the ocean. Dr. Al-Shura has 14 continuous years of formal education involving Traditional Chinese Medicine (TCM) clinical practice, advanced medical study, research and education between the United States, Italy, and China. In 2004, her master’s degree in Oriental Medicine was earned from East West College of Natural Medicine in Florida, USA. In mainland China between 2004 and 2014, she earned hospital study, advanced scholar, and specialty certificates in Chinese medicine, internal medicine, and surgery and cardiology from several university-affiliated hospitals. Those hospitals include Shandong University of Traditional Chinese Medicine, Shandong Provincial Hospital, and Tianjin University of Traditional Chinese Medicine. Her subspecialty training in TCM is in interventional cardiology involving the catherization lab. Dr. Al-Shura earned her PhD in medical education in 2014 through the University Ambrosiana program. Her dissertation on Integrative Cardiovascular Chinese Medicine (ICCM) became her first textbook entitled, Integrative Cardiovascular Chinese Medicine: A Personalized Medicine Perspective. This book was one of 7 textbooks written to introduce the concepts of ICCM. All were published and released together through Elsevier Academic Press in 2014. Those textbooks are utilized for the level 1 program studies in ICCM with continuing medical education (CME) courses. Eight additional textbooks were written on the establishment and development of intermediate ICCM theories and practices. Those textbooks are utilized for the level 2 program CME studies in ICCM. Those 8 textbooks are part of the Integrative Cardiovascular Chinese Medicine series and were published and released together through Elsevier Academic Press in 2019. Dr. Al-Shura is currently a faculty member at Everglades University in Florida, where she teaches medical and healthcare course in the Bachelors of Alternative Medicine program. She also has the Niambi Wellness Institute, based in Florida and Kentucky, where ICCM research and work continues. It includes a natural pharmacy lab and a CME program. The natural pharmacy researches, formulates, manufactures, and distributes various patented and original formulations using TCM herbs. The CME program includes TCM cardiology courses which grant credits towards NCCAOM, state medical board, and state TCM board license renewals in the United States.

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Other Titles by Dr. Anika Niambi Al-Shura • Integrative Cardiovascular Chinese Medicine: A Prevention and Personalized Medicine Perspective • Health Communications in Traditional Chinese Medicine • Integrative Anatomy and Pathophysiology in Traditional Chinese Medicine • Physical Examination in Cardiovascular Chinese Medicine • Diagnosing in cardiovascular Chinese medicine • Essential Treatments in Cardiovascular Chinese Medicine 1: Hyperlipidemia • Advanced Clinical Therapies in Cardiovascular Chinese Medicine

I

SECTION

Intake and narrative

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1 Intake techniques Chapter Objectives The objectives of this chapter are: 1. to discuss intake techniques as necessary for the cardiovascular patient; 2. to discuss the practitioner's bedside manner and patientepractitioner relationship, including empathy and awareness; 3. to present the information collection and intake forms necessary for the cardiovascular patient; 4. to discuss the personal history of the cardiovascular patient based on family, gender, symptoms, medications/formulations, surgeries, and outpatient procedures; 5. to discuss the management of patient care.

Practitioner bedside manner Initiating discussion about cardiovascular history with patients Bedside manner includes professionalism, empathy, awareness of patient cues, tact, diplomacy, good communication skills, good clinical skills, and concern about the patient. Patients want to feel that their health practitioner is someone who can be trusted with personal information and is a leader who can guide them through phases of disease stages and the treatment and recovery process. When initiating discussions about cardiovascular history, it is best to remain neutral about the findings and not impose stereotyping and profiling upon patients. Stereotyping and profiling are so typical in cardiology that once a health care practitioner learns the race or ethnicity of the patient, many assumptions and conclusions are made about the patient that not only could turn out to be false, but could potentially obstruct quality patient care.

Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00001-0 Copyright © 2020 Elsevier Inc. All rights reserved.

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Chapter 1 Intake techniques

Preparing for the visit to ensure focus on the patient Review the initial patient intake and future follow-ups before entering the room, to know ahead of time the plan or approach to the therapeutic process during the visit. Make sure any test results authorized from other health practitioners and facilities have arrived and any test results from ordered labs are back or at least on a return status. Anticipate patient questions about what treatments/medicines will be provided and the direction of therapy. Before entering the room: • Make sure your emotions are calm and centered. Nobody wants a fidgeting and distracted health care practitioner. • Attention is focused and you are ready to respect the patient as a person. • Remember that quality care is the intention. • Knock on the door before entering.

Establishing or reinforcing the patientepractitioner relationship Be kind: • Many patients with symptoms of illness may not be expressing their regular life personality. • Grouchy patients are often living with a chronic condition that may cause pain. They may also be fearful due to ignorance or uncertainty. • Always plan to provide quality care even when a patient is not nice. • Overweight and obese patients have various if not countless reasons for their appearance. Some of these types of patients may not be eating and may be showing signs of malnutrition. • Make eye contact, and smile. • Be polite and greet the patient; people feel more at ease when the physician is friendly. Use the patient’s social salutation or professional title (when applicable) followed by their last name, unless the patient is a child. Then the first name or nickname is appropriate. • Shake the patient’s hand, unless it is certain that a cultural practice prohibits it. • Sit down at patient eye level and ask the patient about the chief complaint. • Actively listen by remaining quiet and showing interest in the patient’s narrative.

Chapter 1 Intake techniques

• • • • • • • • • • • • •

•

• • • •

• Listen to help the patient feel at ease about disclosing potentially embarrassing information. • Listen for any clues that confirm diagnostic findings. • Do not listen to the end, just to ignore what was said and issue the diagnosis you were waiting to give. Be empathetic: Respect patients as people. Use the pain scale or other criterion/method to allow the patient more accurate reporting of symptom severity or likelihood to maintain compliance, etc. Patients may have their own way of reporting symptoms. Patients may have personal beliefs that are normal and commonplace to them. Patients have opinions about the expected care. Take what patients say seriously. Patient trust is crucial. When patients begin to argue about what they are convinced about their health symptoms from their own research, deal with the arguing by agreeing with the patient. Think of a time in life when you were ill and vulnerable, which will help to realize how the patient may be feeling. Validate patient concerns. Do not judge patients to their face about what you do not like and what they are doing wrong with their lives. The clinical approach must be done with competence: Maintain control of personal emotions. Use sharp focus to observe patients: how they walk into the room, how they mount the exam table, how and what they say to answer interrogations, and their personal appearance, body language, behavior, voice pitch, and tone. Validate patient concerns by examining patients. • At the least, view and touch the complaint. • Provide any other appropriate and routine examination. • Many health practitioners feel that they know without looking at the area of complaint. Remember, an aneurysm, pitting edema, and other such health conditions must be palpated. Also, foot pain and swelling could be gangrene inside of a sock, for all you know! • Provide a diagnosis. Give detailed descriptions of care management plans. Advise and guide on next steps in diagnosing and treatment. Provide reasonable future follow-up dates. Ensure HIPAA and other forms of patient privacy.

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Chapter 1 Intake techniques

Collecting information: cardiovascular patient intake form

Cardiovascular Patient Intake Patient Name:__________________ Date of Birth:_______________

Todays Date:____________ Gender: □ Male □Female □Other

Family Cardiovascular Disease History: Mother □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □anemia □congestive heart failure □any cardiomyopathy □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Father □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □anemia □congestive heart failure □any cardiomyopathy □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Sibling: M F □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □anemia □congestive heart failure □any cardiomyopathy □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Grandmother: □pat □mat □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □congestive heart failure □any cardiomyopathy □anemia □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Grandmother: □pat □mate □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □congestive heart failure □any cardiomyopathy □anemia □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Grandfather □pat □mat □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □congestive heart failure □any cardiomyopathy □anemia □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

Grandfather □pat □mat □living □deceased: age___

□hypertension □coronary artery disease □Diabetes □anemia □congestive heart failure □any cardiomyopathy □endocarditis □arrhythmia □pericarditis □hypercholesterolemia □myocardial infarction □none

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Female only : Age of first menstrual period:____ Age menstrual period ended: _____ □currently pregnant □# live births ____ □# miscarriages □#abortions_____ □hysterectomy □ovaries removed □partial/full mastectomy 1. Cardiovascular Disease Symptom History: □hypertension □ coronary artery disease □congestive heart failure □ any cardiomyopathy □pericarditis □ hypercholesterolemia

□Diabetes □ anemia □endocarditis □ arrhythmia

Have you ever had a heart attack? □yes □no Date of last event:___________________ Hospital visited: _______________________ City, State:_____________________ Do you have Diabetes? □yes □no Year diagnosed:_________________ Age diagnosed:________ Do you have congenital disorder affecting the cardiovascular system? □yes Disorder:____________________________ Year diagnosed:_________________ Age diagnosed:________

□no

Do you have a history of atrial fibrillation (AF)? □yes □no Aware when you are in AF? □yes □no Type of AF: Intermittent □Continuous □Duration:___________________ Please check any of these you have ever had: □cardioversion □EP study □cardiac ablation □echocardiogram □pacemaker: type, brand and model___________________ Vascular Disease Symptom History: □peripheral vascular disease □renal insufficiency □peripheral vascular disease □any aneurysm □deep vein thrombosis (circle): arm leg 2. Current Medications/Herbal Remedies/ Nutritional Supplements: □lipid lowering □ blood pressure □ blood □ Diabetes □daily aspirin □ diuretic □ anxiety/depression □ psychosis □gastrointestinal □ antibiotics □ respiratory □ kidney/bladder □neurological □ dermatological □gynecological □ endocrine □ENT □ orthopedic □weight loss □ cardiovascular □energy □ relaxation/sleep □thought/focus □ cancer □infection □ pain □ detox □ weight gain □lymphatic □ immune system □ hepatic/biliary □ splenic

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Chapter 1 Intake techniques

List: Allergy history: □no □yes □seasonal: _______ □contact: _______ □plant: _______

□animal/insect: _______

□chemical: _______ □mineral: _______ □medication: ________ □contrast: _______ □Drug □herb/formula □supplement Name: _____________________ Date prescribed/began: ____________ Dosage:__________________ Health reason for taking this:___________________________________ __________________________________________________________ □Drug □herb/formula □supplement Name:_____________________ Date prescribed/began:____________ Dosage:__________________ Health reason for taking this:___________________________________ __________________________________________________________ □Drug □herb/formula □supplement Name:_____________________ Date prescribed/began:____________ Dosage:__________________ Health reason for taking this:___________________________________ __________________________________________________________ □Drug □herb/formula □supplement Name:_____________________ Date prescribed/began:____________ Dosage:__________________ Health reason for taking this:___________________________________ __________________________________________________________ 3.Surgical History: Procedure: ____________________________________ Date: _____________ Procedure: ____________________________________ Date: _____________ Procedure: ____________________________________ Date: _____________ Procedure: ____________________________________ Date: _____________ Procedure: ____________________________________ Date: _____________ 4. Cardiac Outpatient History: □Cardiac stress test Location:___________________________ Date:_________ Result: pos □Cardiac catheterization Location:___________________________ Date:_________ Result: pos □MRI Location:___________________________ Date:_________ Result: pos

neg neg neg

Chapter 1 Intake techniques

□CT Scan Location:___________________________ Date:_________ Result: □Chest X-ray Location:___________________________ Date:_________ Result: □Echocar diogram Location:___________________________ Date:_________ Result: □EP Study Location:___________________________ Date:_________ Result: □Nuclear scan Location:___________________________ Date:_________ Result:

pos

neg

pos

neg

pos

neg

pos

neg

pos

neg

Other significant medical or surgical history that you think we should know about? If so, please describe them in the space below.

Patient Signature: _________________________________Date:___________ © 2019 Anika Niambi Al-Shura. Published by Elsevier Inc. All rights reserved.

Family cardiovascular disease history Purpose: Obtain a family cardiovascular disease history to determine genetics, health history, birth history, death causes, environmental lifestyle habits, possible cultural observances, and other family traits that predispose a patient to cardiovascular diseases. Discuss patient concerns for the chief complaint and any branch issues. Bedside manner: Ask questions according to the entries in the intake. Ask patients what their race and ethnicities are and whether those demographics have any historical significance in that patient’s family. Offering genetic testing where applicable can help to bring new awareness not known before. Ask how the patient feels about life, what type of work/school life he or she may have, where he or she lives, if he or she lives alone, who the members of the household are, and about the relationship dynamics. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

Female only history Purpose: Obtain a “female only” history to determine the age of menarche and menopause/hysterectomies, births, abortions,

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and breast cancer history. All have potential markers and risk factors that predispose a patient to cardiovascular diseases. Bedside manner: Ask questions according to the entries in the intake. Ask patients what their cardiac symptoms are and when the cardiac symptoms began; compare them to female milestones and determine connections. Be empathetic to patient circumstances such as female-born patients who never had a menarche, female patients who may have had a hysterectomy earlier in life, pregnant patients, and transgender female patients, who will not have experienced earlier or later milestones specific to genetically female patients. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

Cardiac disease symptoms Purpose: Obtain a cardiac disease symptoms history to determine what symptoms the patient has experienced and compare with other histories, findings on current and previous physical examinations, and diagnostic tests. All have potential to give clues to markers and risk factors that can predispose a patient to cardiovascular diseases. Bedside manner: Ask questions according to the entries in the intake. Ask patients what their cardiac symptoms are, when the cardiac symptoms began, about the quality and severity of the symptoms, how the primary care physician and cardiologist in Western medicine manage care for any confirmed diagnoses, about relevant hospital emergency room visits, and about quality of life and disability as a result of the cardiovascular disease condition or other diseases that exacerbate symptoms in confirmed cardiovascular diseases. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

Current medications/herbal formulas and nutritional supplements Purpose: Obtain a history of current medications/herbal formulas and nutritional supplements to determine what other licensed practitioners with prescribing scopes have actually prescribed or suggested for confirmed diagnosed cardiovascular diseases. Bedside manner: Keep an open mind to learn the benefits for patients taking any monitored integration of pharmaceutical drugs and herbal formulas together or separately for certain

Chapter 1 Intake techniques

diagnosed cardiovascular diseases. Confirm existing remedies and note any compatibilities and contraindications for interactions. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

Surgical history Purpose: Obtain a surgical history to determine what past surgical procedures may or may not be related to cardiovascular diseases. Check past medical records for any complications with anesthesia, drugs, vitals, and blood levels that should be considered during cardiovascular treatment. Bedside manner: Ask questions according to the entries in the intake. Ask patients what their cardiac symptoms are, when the cardiac symptoms began, about the quality and severity of the symptoms, how the primary care physician and cardiologist in Western medicine manage care for any confirmed diagnoses, about relevant hospital emergency room visits, and about quality of life and disability as a result of a cardiovascular disease condition or other diseases that exacerbate symptoms in confirmed cardiovascular diseases. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

Cardiac outpatient history Purpose: Obtain a cardiac outpatient history to determine what symptoms the patient has experienced and compare with other histories, findings on current and previous physical examinations, and diagnostic tests. All have potential to give clues to markers and risk factors that can predispose a patient to cardiovascular diseases. Bedside manner: Ask questions according to the entries in the intake. Ask patients what their cardiac symptoms are, when the cardiac symptoms began, about the quality and severity of the symptoms, how the primary care physician and cardiologist in Western medicine manage care for any confirmed diagnoses, about relevant hospital emergency room visits, and about quality of life and disability as a result of a cardiovascular disease condition or other diseases that exacerbate symptoms in confirmed cardiovascular diseases. Follow-up: Discuss any family cardiac history concerns for the chief complaint and any branch issues.

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Managing patient care Cardiovascular History Patient Name:__________________ Date of Birth:___________________

Todays Date:________________ Gender: □ Male □Female □Other

Current Vitals and Cardiovascular Profile : Height: Weight: BP: / EKG: HR: Resp: O2 Sat: Hb: Creatinine: Rhythm: Sinus AF Other: LV Function: good/ mild/ mod/ severe impairment Personal Cardiovascular History: Date of Cardiac Event: / Troponin: Classification NYHA Hypertension Dyspnea Angina

/

Diagnosing Previous Myocardial Infarction Previous Cerebral Infarction/ CVA/ TIA Previous / Most Recent PCI Diabetes Diagnosis Renal Impairment with Creatinine Study Hypertension Diagnosis Peripheral Vascular Disease Diagnosis Varicose Veins Carotid Bruit Hypercholesterolemia Diagnosis Smoker

□ BNP

□ STEMI/ NSTEMI □

I

II

III

IV

NO YES Date:

Other Comorbidities:

Patient Signature:_________________________________Date:___________ © 2019 Anika Niambi Al-Shura. Published by Elsevier Inc. All rights reserved.

Chapter 1 Intake techniques

Current vitals and cardiovascular profile Purpose: A current vitals and cardiovascular profile helps in comparing past findings with the current ones for health care and in responding to monitoring of diagnostic methods or health maintenance. Bedside manner: Ask questions when past entries differ dramatically from a recent previous visit relative to a setback. Also, acknowledge and appreciate the progress a patient is making toward health goals. Point out deficits during the current visit and team up with cooperative and compliant patients on how to improve. Follow-up: Give the therapeutic process a time frame and set a future appointment to explore patient observations during the process and compare them with diagnostic follow-up findings.

Personal cardiovascular history Purpose: A personal cardiovascular history keeps a record of past cardiovascular events for use in comparing them with future progress and setbacks during therapy. Bedside manner: Address the history as a way to determine whether the current health condition is or is not indicated for traditional Chinese medicine care. Follow-up: For conditions indicated for traditional Chinese medicine, the therapeutic process includes a time frame with future appointments set at close intervals to explore patient observations during the process and compare them with diagnostic follow-up findings.

Other comorbidities Purpose: A record of other comorbidities helps to acknowledge and include other health conditions that may have a connection to the cardiovascular profile in the chart. Bedside manner: Ask questions about key information from the patient’s narrative that, backed up with diagnostic evidence, provides enough information to consider how using the five elements and syndrome differentiation in traditional Chinese medicine may connect elements of the bigger picture of cardiovascular disease that Western medicine perspectives either choose not to connect or neglect completely for some reason. Follow-up: Give the therapeutic process a time frame and set a future appointment to explore patient observations during the process and compare them with diagnostic follow-up findings.

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Further reading Bruno KA, Mathews JE, Yang AL, et al. BPA Alters Estrogen Receptor Expression in the Heart After Viral Infection Activating Cardiac Mast Cells and T Cells Leading to Perimyocarditis and Fibrosis. Front Endocrinol (Lausanne). 2019; 10:598. https://doi.org/10.3389/fendo.2019.00598. Published 2019 Sep 4. Chacar S, Hajal J, Saliba Y, et al. Long-term intake of phenolic compounds attenuates age-related cardiac remodeling. Aging Cell. 2019;18(2):e12894. https://doi.org/10.1111/acel.12894. Herring N, Tapoulal N, Kalla M, et al. Neuropeptide-Y causes coronary microvascular constriction and is associated with reduced ejection fraction following ST-elevation myocardial infarction. Eur Heart J. 2019;40(24): 1920e1929. https://doi.org/10.1093/eurheartj/ehz115. Kim C, Sung J, Lee JH, et al. Clinical Practice Guideline for Cardiac Rehabilitation in Korea. Korean J Thorac Cardiovasc Surg. 2019;52(4): 248e285. https://doi.org/10.5090/kjtcs.2019.52.4.248. O’Donnell M, Mente A, Rangarajan S, et al. Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: prospective cohort study. BMJ. 2019;364:l772. https://doi.org/10.1136/ bmj.l772. Published 2019 Mar 13. Øyen N, Olsen SF, Basit S, et al. Association Between Maternal Folic Acid Supplementation and Congenital Heart Defects in Offspring in Birth Cohorts From Denmark and Norway. J Am Heart Assoc. 2019;8(6):e011615. https:// doi.org/10.1161/JAHA.118.011615. Pedra SRFF, Zielinsky P, Binotto CN, et al. Brazilian Fetal Cardiology Guidelines 2019. Arq Bras Cardiol. 2019;112(5):600e648. https://doi.org/10.5935/ abc.20190075. Published 2019 Jun 6. Sokolova M, Sjaastad I, Louwe MC, et al. NLRP3 Inflammasome Promotes Myocardial Remodeling During Diet-Induced Obesity. Front Immunol. 2019; 10:1621. https://doi.org/10.3389/fimmu.2019.01621. Published 2019 Jul 16. van de Vegte YJ, Tegegne BS, Verweij N, Snieder H, van der Harst P. Genetics and the heart rate response to exercise. Cell Mol Life Sci. 2019;76(12): 2391e2409. https://doi.org/10.1007/s00018-019-03079-4. Wang CC, Wu CK, Tsai ML, et al. Focused Update of the Guidelines of the Taiwan Society of Cardiology for the Diagnosis and Treatment of Heart Failure. Acta Cardiol Sin. 2019;35(3):244e283. https://doi.org/10.6515/ ACS.201905_35(3).20190422A, 2019.

2 Patient narrative techniques Chapter Objectives: 1. To discuss the relevancy of ADLs and general health progress entries from a patient diary and narrative techniques that prepare them for clinical visits 2. To discuss what the patient should gather and provide for a discussion with a cardiologist and traditional Chinese medicine specialist 3. To list the important logs to consider in the patient health diary such as diet, health vitals monitoring and symptom monitoring

Patient preparation for clinical visits The cardiac patient has the responsibility of bringing his or her daily health diary to the clinical visit. The health diary is a record of alleged compliance. Conscientious patients will chronical what they do throughout the day, so that issues can be addressed and new directives can be implemented. The initial setup of the diary should be detailed centering on the activities of daily living (ADLs) so that the patient can remain organized and to manage his or her days. Goals tracked for the patients include: • managing weight; • documenting exercise/physical activity; • documenting taking scheduled medication, herbal formulas, and supplements; • managing or reducing risk for high blood pressure; • managing or reducing risk factors for diabetes; • managing or reducing risk factors for heart failure; • managing or reducing risk factors for stroke. Entries for an ADL diary:

(Continued) Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00002-2 Copyright © 2020 Elsevier Inc. All rights reserved.

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Entries for a health diary:

Talking to the cardiologist and traditional Chinese medicine specialist Before the appointment: • Get copies of your recent medical records and test results, films on CD, and X-rays. • Make a list of any genetic tests done and as much as is known about family cardiac history and personal health and cardiac history. • Make a list of all prescription drug medications and herbal formula medications taken within the past 2 years and all current drug and herbal formula medications, over-the-counter remedies, and nutritional supplements. It would be beneficial to have an analysis written during the time of regimen of how each medication made you feel in response to its activation after ingestion. • Follow-up patients should write down what has happened since the last medical visit, even if the visit was not in the current clinic. Some patients visited the emergency room, have medication reactions or new symptoms, and need to be seen. • Make a list of current symptoms and what relieves them or makes them worse. • Make sure the daily health diary is complete and up to date. Include a side note that lists symptoms and what relieves them or makes them worse. Day of the appointment: • Bring the collection of medical records, lists, and symptom descriptions for the physician to evaluate. • Bring someone you trust, such as a friend or family member, to help listen and ask important questions. • Write down information given during the visit in the form of questions to ask the clinician during the visit: • What is the cardiovascular test for and what does it involve? • What are the risks? • What are we looking for or not looking for?

Chapter 2 Patient narrative techniques

• When will the results arrive? • After the results arrive, what other cardiovascular or other tests might be ordered to continue to search for clues or a cause? • What is the cardiovascular diagnosis? • How will this diagnosis affect my life? • Is there a possibility that my condition would improve without medication? • What will this treatment do for me and to the disease? • What are the possible cardiovascular or other organ system and life-functioning risks and benefits to this treatment? • What are we looking for this treatment to accomplish? • Are there side effects of the medication? • How often should the medicine be taken? • Is this treatment short term or long term? • Should I discontinue any other drug or herbal prescription I am currently taking? • Should I modify or change my lifestyle for the medication? • Should I modify or change my diet for this medication? • What kinds of changes to lifestyle and/or diet should I make? • What other medicines might be needed during treatment? • Are there any alternatives to this medicine that will work effectively? • How often will I need to follow up for the medication or progress in my condition? • What would be expected during future visits? • If there is a chance of emergency visit to the hospital, should the physician be notified, or should a new followup visit be made immediately after discharge? • If I get a second opinion, do you have any suggestions? • If a procedure is to be performed, will you be doing it in the office or at another facility, or will another physician be performing it at his or her venue?

Important logs to consider when a patient creates or modifies an ADL diary Diet: • Watching daily sodium intake • Watching sugar intake • Watching water and other fluid intake • Watching food intake, whether to increase or decrease amount of food

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• Watching medication times in relationship to food/fluid intake • Watching body waste voiding times in relationship to food/ fluid intake • Watching how many times food intake is suggested per day • Watching the effects on health after food/fluid intake Health vitals monitoring: • Taking the blood pressure and pulse at the same times daily • Taking blood sugar measurement at the same times daily • Monitoring and recording O2 saturations upon feeling breathless • Taking weight measurement at the same time daily with or without clothing, with or without prior meal or emptying the bladder • Taking drug and herbal formula medication and recommended nutritional supplementation • Logging when the cravings to smoke cigarettes or drink alcohol occur and what was done about it Symptom monitoring: • Balancing physical activity with rest at the same times daily • Monitor heart failure symptoms daily and when to call emergency transport services to go to the nearest hospital: • Chest pain • Shortness of breath • Being awakened from sleep with breathing difficulties • Frothy or pink sputum • Sudden weight gain • Change in blood pressure • Dizziness or fainting • Coughing: dry hacking or wet sputum-filled expectorant • Medication problems • Changes in heart rate

Further reading Biglino G, Bucciarelli-Ducci C, Caputo M, et al. Towards a narrative cardiology: exploring, holding and re-presenting narratives of heart disease. Cardiovasc Diagn Ther. 2019;9(1):73e77. https://doi.org/10.21037/cdt.2018.11.03. McGoon MD, Ferrari P, Armstrong I, et al. The importance of patient perspectives in pulmonary hypertension. Eur Respir J. 2019;53(1):1801919. https://doi.org/10.1183/13993003.01919-2018. Published 2019 Jan 24. Piek JJ. Gender differences: it’s time for a rational approach. Neth Heart J. 2019; 27(5):227e228. https://doi.org/10.1007/s12471-019-1277-7. Schofield T, Bhatia RS, Yin C, Hahn-Goldberg S, Okrainec K. Patient experiences using a novel tool to improve care transitions in patients with heart failure: a qualitative analysis. BMJ Open. 2019;9(6):e026822. https://doi.org/10.1136/ bmjopen-2018-026822. Published 2019 Jun 24.

Chapter 2 Patient narrative techniques

Seong HJ, Lee K, Kim BH, Son YJ. sentence case. Int J Environ Res Public Health. 2019;16(15):2698. https://doi.org/10.3390/ijerph16152698. Published 2019 Jul 29. Simonÿ C, Andersen IC, Bodtger U, Birkelund R. Breathing through a troubled life - a phenomenological-hermeneutic study of chronic obstructive pulmonary disease patients’ lived experiences during the course of pulmonary rehabilitation. Int J Qual Stud Health Well-being. 2019;14(1): 1647401. https://doi.org/10.1080/17482631.2019.1647401.

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II SECTION

Inquiry and examination

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3 Inquiry and examination techniques Chapter Objectives 1. To discuss interviewing patients and reporting of useful techniques 2. To discuss the positioning of the body during interviewing patients using S.O.L.E.R 3. To discuss establishing a rapport with patients and respecting privacy 4. To discuss asking open-ended questions to gather insight 5. To discuss recording information from the patient's diary including the dates, time of day, medication dosage, meal times, activities of daily living, and health status

Interviewing patients and reporting useful information Consider the culture of the patient Research the number of different cultures of people living in the local community. Get to know various way of life, norms, and methods of respect among their hierarchies.

Position your body comfortably at a speaking level where the patient is sitting or standing • Do not tower in height level over the patient while speaking with him or her. • If positioning is difficult or impossible because of personal physical limitations, position yourself where it is most comfortable to communicate with the patient and make sure it is comfortable for the patient to communicate with you. • Make sure the patient can look at you eye to eye and at your mouth when you speak. This form of interaction sets the mood for trust in many cultures. • Make sure you pay attention to the facial expressions of the patient and emotional cues. Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00003-4 Copyright © 2020 Elsevier Inc. All rights reserved.

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S.O.L.E.R It is best to be careful about appearing approachable using verbal and nonverbal skills in communication. The clinical encounter can last as little as a few minutes, and during that time, a lot of important information must be gathered for diagnosing, management, or transitioning. SOLER is a pneumonic that is used as a reminder to position yourself with a patient for the patient’s benefit. Five principles of SOLER: • Sit squarely in front of the patient • Open posture, with the arms on the lap, without ever crossing them on the chest • Lean forward toward the person to whom you are speaking • Eye contact with the person with whom you are speaking • Relax the body and mind away from yourself and focus on the patient

Establish rapport with the patient Patients are more likely to be forthcoming with information about their history and their present with practitioners who are professional and who take the time to communicate with their patients.

Respect patient privacy Patients are more likely to trust the judgment of a practitioner who provides a private, safe place to disclose information. Information that is crucial to know about a patient’s history or present condition, such as sexual practices, pregnancy, substance abuse, mental health, and certain diseases, should not be discussed in places where others may hear the information.

Ask open-ended questions, then listen and provide insight that leads toward a path to diagnosis Patients are more likely to disclose details of a situation or condition according to how a question is asked. During the interview, if patients are asked direct questions that require only a “yes” or “no” answer, such answers provide no meaningful insight. Asking about what caused or what was happening around the time of the chief medical problem can help encourage the patient to provide useful clues to help with planning the steps in diagnosis or management. Ask additional questions according to actively listening

Chapter 3 Inquiry and examination techniques

to the patient instead of simply going down a list at first. Allow the patient space to provide information and then fill the gaps of your investigation by asking other necessary questions in the end. While providing insight into the patient’s condition or a base to investigate a diagnosis, or even the diagnosis, consider the language used. Medical terminology in Western medicine is confusing enough for most people. When traditional Chinese medicine terms and differentiation are included, patients are not sure what the information means or how it is used to help. This can embarrass or confuse patients and make them feel that perhaps they are in the care of an amateur whom they cannot trust.

Recording information from the patient diary Documenting dates The date should be the first information provided. Some patients think dates are not important to document since the tasks are done all day, every day. Dates are important because if the updated entries are copied and placed into the patient’s chart, accurate dates show patient activity between clinical visits.

Time of day The time of day that tasks are done helps clarify important details such as life-saving medication dosages (i.e., insulin or O2) in relationship to meals eaten and exercise. Updated entries should be copied and placed into the patient’s chart; the accurate information details patient activity between clinical visits.

Medication and dosage Medication dosages should be in line with the dates and in relationship to meals eaten and sleep/activity. The purpose is to study activity, pharmacodynamic effectiveness, and side effects and to prevent cross-interaction issues and overdose. Updated entries should be copied and placed into the patient’s chart; the accurate information details patient activity between clinical visits. Information about prescribed herbal formulas, nutritional supplements, and medications that must be disclosed to the patients without them having to ask includes: • medication duration • purpose of the prescription • the risks of taking or not taking the prescription • how and when to take the medication

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• how to know that the medication is working • food, drinks, and other medications, herbs, and supplements to avoid • what to do about missing doses • possible side effects and what to do about them.

Meal content Patients on prescriptions should eat meals at the same time daily and provide details about the time period before or after taking prescriptions, what was eaten, how much was eaten, how easy it was to feed him- or herself, how long it took to eat, how much food was left over, how he or she felt after eating, and what activity was done after the meal. The purpose is to study activity and nutritional and fluid intake and output. Updated entries should be copied and placed into the patient’s chart; the accurate information details patient activity between clinical visits. Information about meal content must be disclosed to patients without them having to ask, including: • information about meals that should go into the diary • foods to eat or avoid • whether to control food portions and fluid intake • reading food labels for ingredient and nutritional content • cooking, including tips to follow versus eating at restaurants • information about visiting a nutritionist or dietitian and joining groups in the community.

Activities of daily living Activities of daily living include waking up for the day, eating meals, dressing and grooming, daily tasks, appointments, errands, exercise, rest, and retiring to bed. Updated entries should be copied and placed into the patient’s chart; the accurate information details patient activity between clinical visits. Information about conducting daily activities must be disclosed to patients without them having to ask, including: • how medication will affect sleep/wake balance and schedule • movement after rousing, waking and ambulating in the living areas • types of activities to engage in, exercise and sports to participate in • amount of exercise that is necessary • information about smoking and alcohol rationing and cessation.

Chapter 3 Inquiry and examination techniques

Health Patients should report how they feel every day. Sometimes it is best to help people become more aware and on schedule by reporting feelings around sleep and meal times. Updated entries should be copied and placed into the patient’s chart; the accurate information details patient activity between clinical visits.

Further reading Bellander T, Karlsson AM. Patient participation and learning in medical consultations about congenital heart defects. PLoS One. 2019;14(7):e0220136. https://doi.org/10.1371/journal.pone.0220136. Published 2019 Jul 24.
n G, Spaak J, von Arbin M, Franze
n-Dahlin Å, Stenfors T. Health care Eve professionals’ experiences and enactment of person-centered care at a multidisciplinary outpatient specialty clinic. J Multidiscip Healthc. 2019;12: 137e148. https://doi.org/10.2147/JMDH.S186388. Published 2019 Feb 14. Hansen KA, McKernan LC, Carter SD, Allen C, Wolever RQ. A Replicable and sustainable whole person care model for chronic pain. J Altern Complement Med. 2019;25(S1):S86eS94. https://doi.org/10.1089/acm.2018.0420. Langford AT, Williams SK, Applegate M, Ogedegbe O, Braithwaite RS. Partnerships to improve shared decision making for patients with hypertension - health equity implications. Ethn Dis. 2019;29(Suppl 1): 97e102. https://doi.org/10.18865/ed.29.S1.97. Published 2019 Feb 21. Magnani JW, Mujahid MS, Aronow HD, et al. Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the American heart association. Circulation. 2018; 138(2):e48ee74. https://doi.org/10.1161/CIR.0000000000000579. Ofili EO, Schanberg LE, Hutchinson B, et al. The association of black cardiologists (ABC) cardiovascular implementation study (CVIS): a research registry integrating social determinants to support care for underserved patients. Int J Environ Res Public Health. 2019;16(9):1631. https://doi.org/ 10.3390/ijerph16091631. Published 2019 May 10. Okunrintemi V, Valero-Elizondo J, Patrick B, et al. Gender differences in patientreported outcomes among adults with atherosclerotic cardiovascular disease. J Am Heart Assoc. 2018;7(24):e010498. https://doi.org/10.1161/ JAHA.118.010498. Pang B, Memel Z, Diamant C, Clarke E, Chou S, Gregory H. Culinary medicine and community partnership: hands-on culinary skills training to empower medical students to provide patient-centered nutrition education. Med Educ Online. 2019;24(1):1630238. https://doi.org/10.1080/10872981.2019.1630238. € ller H, Köstler U, et al. Quality of health care with regard to Peltzer S, Mu detection and treatment of mental disorders in patients with coronary heart disease (MenDis-CHD): study protocol. BMC Psychol. 2019;7(1):21. https:// doi.org/10.1186/s40359-019-0295-y. Published 2019 Apr 8. Roberts BW, Roberts MB, Yao J, Bosire J, Mazzarelli A, Trzeciak S. Development and validation of a tool to measure patient assessment of clinical compassion. JAMA Netw Open. 2019;2(5):e193976. https://doi.org/10.1001/ jamanetworkopen. 2019. 3976. Published 2019 May 3. Safdar B, Nagurney JT, Anise A, et al. Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular

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Research Workgroup. Acad Emerg Med. 2014;21(12):1350e1360. https:// doi.org/10.1111/acem.12527. Savitz ST, Dobler CC, Shah ND, et al. Patient-clinician decision making for stable angina: the role of health literacy. EGEMS (Wash DC). 2019;7(1):42. https:// doi.org/10.5334/egems.306. Published 2019 Aug 9. Schofield T, Ross H, Bhatia RS, Okrainec K. Feasibility and performance of a patient-oriented discharge instruction tool for heart failure. BMJ Open Qual. 2019;8(3):e000489. https://doi.org/10.1136/bmjoq-2018-000489. Published 2019 Aug 19. Schofield T, Bhatia RS, Yin C, Hahn-Goldberg S, Okrainec K. Patient experiences using a novel tool to improve care transitions in patients with heart failure: a qualitative analysis. BMJ Open. 2019;9(6):e026822. https://doi.org/10.1136/ bmjopen-2018-026822. Published 2019 Jun 24. Yu Y, Gupta A, Wu C, et al. Characteristics, management, and outcomes of patients hospitalized for heart failure in China: the China PEACE retrospective heart failure study. J Am Heart Assoc. 2019;8(17):e012884. https://doi.org/10.1161/JAHA.119.012884. Zhang L, Babu SV, Jindal M, Williams JE, Gimbel RW. A patient-centered mobile phone app (iHeartU) with a virtual human assistant for self-management of heart failure: protocol for a usability assessment study. JMIR Res Protoc. 2019;8(5):e13502. https://doi.org/10.2196/13502. Published 2019 May 23.

III SECTION

Disorders, treatment principles & plans

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4 Chest pain Chapter Objectives: 1. To discuss the etiology of chest pain from the perspectives of western medicine and traditional Chinese medicine 2. To discuss patient inquiry and physical examination concerning the complaints of chest pain 3. To describe differential diagnosing to rule out cardiovascular causes of chest pain

Part 1: Direct symptoms Definition Chest pain is an unpleasant and possibly severe sensation that originates in or radiates around the chest. It is characterized by a feeling of pressure, tightness, or discomfort.

Etiology The pain signals may be transmitted by the vagus and phrenic nerves and may also originate or be felt or palpated around the ribs and intercostal tissues, or the sensation may be felt in the esophagus, diaphragm, scapulae, or spine.

Genetic factors • DKN2A and DKN2B • These genes are involved with the formation of plaque within the arteries. • They may indicate a risk factor for coronary artery disease. • MTAP • Expression of this gene facilitates the processing of cellular waste products into methionine. • Methionine metabolizes excess homocysteine.

Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00004-6 Copyright © 2020 Elsevier Inc. All rights reserved.

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Chapter 4 Chest pain

Chinese medicine factors

Chinese medicine causes and symptoms of chest pain Stagnation

Deficiency

Blood Phlegm Cold Qi Yin Yang

Stabbing, fixed pain, sudden onset of which is worse at night Chest oppression, heavy chest sensation, cough with mucus, fatigue and dizziness Pain that is worse with cold, shortness of breath, and a preference for warmth Fatigue, low energy, and shortness of breath Fatigue, night sweats, afternoon fever, and malar flush Fatigue, cold body sensation, pale face, body edema, and profuse clear urination

• Acute chest pain • Initial onset with a short or unstable duration • Cause may involve: • Angina pectoris (xiong bi) • Myocardial infarction (possible separation of yin and yang) • Requires first responder assistance and transport to a hospital facility for emergency attention • Differentiation of syndromes • Uses five element theory to determine the magnitude and extent of single and multiple organ disorders, their impact on organ systems, and the health prognosis of the patient • Determined initially according to interrogation • Followed up through tongue and pulse study • Observed through symptoms and signs of patient behavior and appearance during the office visit • Causes of chest pain • Stagnation of blood, phlegm, and cold • Deficiency of qi, yang, and yin • Angina pectoris (xiong bi) • Symptoms include pain, radiation in areas of the body, exertion, and stress • Pain quality is associated with symptoms • Triggering stressors can be good or bad

Symptom

Pain quality in angina

Pain due to other causes

Pain Radiation Exertion Stress

Sensation is crushing, dull, or heavy Involves the left or right arm or neck Symptoms are relieved by rest No symptoms

Stabbing, burning, and sharp Shoulders or back May or may not be relieved by rest Emotional or sexual events will trigger

Chapter 4 Chest pain

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Cardiovascular cause Factors Coronary artery disease Myocardial ischemia

Mitral valve prolapse

Pericarditis

Unstable angina pectoris

Myocardial infarction

Aortic dissection

Pericarditis

The pain is relieved 3 min after taking nitroglycerin The pain is relieved after taking nitroglycerin and calcium channel blockers An electrocardiogram shows Q waves and ST segment depressions Blood work includes complete blood count and cardiac enzyme test The pain is not relieved by rest or nitroglycerin Doppler and electrocardiogram are important in diagnosing, especially for vegetations in endocarditis and possible arrhythmias The pain radiates to the left arm and is worse while lying down and relieved by sitting up An electrocardiogram shows Q waves and ST segment depressions The pain is relieved by rest or nitroglycerin An electrocardiogram shows Q waves and ST segment depressions Blood work includes complete blood count and cardiac enzyme test Diagnosis can include coronary artery disease The pain include dyspnea or nausea and is not relieved by rest or nitroglycerin An electrocardiogram shows Q waves and ST segment depressions Blood work includes complete blood count and cardiac enzyme test The pain includes a ripping sensation in the chest and possible absent pulse and is not relieved by rest or nitroglycerin Chest X-ray is important in diagnosing The pain radiates to the left arm and is worse while lying down and relieved by sitting up An electrocardiogram shows Q waves and ST segment depressions

Part 2: Inquiry and examination Chest pain is a very common reason patients visit a physician. The most important task is to determine whether the pain is likely caused by angina pectoris, myocardial ischemia, or coronary artery obstruction. It is important to listen to the patient narrative about the possible reasons, surrounding events, and time period in which the symptoms began; to interrogate with questions concerning points from the narrative; and to conduct a physical examination and diagnostic testing to study and determine a course of action in treatment. Physical examination searches for clues to transitions in health due to manifesting disease conditions often concurrent

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Chapter 4 Chest pain

with and complicating cardiovascular disease to determine the direct and indirect cardiac and noncardiac causes of chest pain: U Check the skin for bumps or a rash associated with autoimmune diseases that contribute to chest discomfort. U Check the lymph nodes for enlargements that are associated with infectious diseases from bacteria, viruses, fungi, and other categories of microbes that may cause damage to the heart and vessels or that lead to obstruction that causes chest pain. U Listen to the heart for normal heart sounds, but detecting abnormal valvular and blood flow sounds; listen to the lungs for normal air passage and abnormal airflow and presence of fluid; listen to the abdominal area for borborygmus. U Palpate for abdominal bloating, constipation, or enlarged liver or spleen. In Chinese medicine, chest pain as well as the possible associated angina pectoris is classified under xiong bi chest obstruction and heartache. The following table lists cardiovascular, pulmonary, and other causes of chest pain.

Pain source

Cause

Symptoms

Cardiovascular causes

Pulmonary causes

Ischemia Nonischemia Obstruction Chest wall Functional Vascular Cough

Other causes

Dyspnea Psychological Gastroesophageal disorders

Myocardial infarction Pericarditis or aneurysm Aortic disorders Pneumothorax and pleuritis Pneumonia, sarcoidosis, cancer, tuberculosis Hypertension, embolus A sharp sound expelled from the lungs and throat and out of the mouth Difficult or labored breathing Neurosis, depression, anxiety Acid reflux, nausea, dysphagia, and vomiting

Cardiovascular causes: ischemia and nonischemia • With history of ischemia, physicians can inquire about a history of: • Myocardial infarction U Obstructed blood flow in the coronary arteries by a section of plaque or clot

Chapter 4 Chest pain

U The lack of blood and oxygen destroys myocardial tissue • Patient may report symptoms that include: U Chest and arm pressure, aching, tightness, pain, or squeezing that may radiate to the jaw, neck, shoulders, and upper back U Digestive sensations of nausea, indigestion, heartburn, or abdominal pain U Respiratory symptoms of labored breathing and shortness of breath with fatigue U Neurological symptoms of lightheadedness and dizziness with cold sweating • Stroke • Physician may engage in a short discussion to determine cognitive effects of stroke and perform neurological tests to determine deficits and root causes that may affect cardiovascular functioning and lead to chest pain. ❖ For ischemia: blockage of carotid vessels by a clot or plaque obstructs blood to the brain. The lack of blood and oxygen destroys brain tissue. U Central nervous system is affected: spinal cord and brain U Peripheral nervous system is affected: autonomic and somatic ❖ Autonomic (sympathetic and parasympathetic) nervous system controls the muscles of the organs and glands. ❖ Somatic nervous system exchanges signals between the organs and the glands with the central nervous system. • Nonischemia: • Stroke ❖ Hemorrhagic: blood escapes into the brain tissue U Central nervous system is affected: spinal cord and brain U Peripheral nervous system is affected: autonomic and somatic ❖ Autonomic nervous system (sympathetic and parasympathetic) controls the muscles of the organs and glands. ❖ Somatic nervous system exchanges signals between the organs and the glands with the central nervous system. • Aneurysm: • Takayasu arteritis • Giant cell arteritis • Untreated infection such as Salmonella and Streptococcus pyogenes • Rupture symptoms

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Chapter 4 Chest pain

•

•

•

•

❖ Sudden intense pain located in the middle of the chest radiating to the back in the same position ❖ Low blood pressure with rapid heart rate ❖ Skin clamminess ❖ Difficulty breathing, speaking, and swallowing ❖ Weakness on one side of the body ❖ Dizziness and lightheadedness with loss of consciousness Atherosclerosis ❖ Older patients age 50þ ❖ Plaque builds up and weakens the artery walls for aneurysm risk ❖ Hypertension puts pressure on the artery walls, causing the balloon ❖ Physician may order an exercise stress test with catheterization lab angiogram or percutaneous coronary intervention Genetic conditions that cause or contribute to chest pain ❖ Seen in younger patients starting at birth ❖ Aortic tricuspid valve develops abnormally as a bicuspid ❖ Connective tissue disorders that affect all bones and muscles ❖ Chest cavity deformities ❖ Marfan syndrome ❖ EhlerseDanlos ❖ LoeyseDietz ❖ Turner syndrome Aortic aneurysm ❖ Found most often in the thoracic cavity ❖ Grows slowly and may not show symptoms or be detected in the process ❖ Symptoms U Tenderness or pain in the chest U Back pain U Hoarseness U Cough U Shortness of breath ❖ Genetic U Marfan syndrome U EhlerseDanlos U LoeyseDietz U Turner syndrome Abdominal aneurysm ❖ Located in the lower aorta ❖ Most common aneurysm ❖ Can be felt upon palpation

Chapter 4 Chest pain

❖ Can be heard on auscultation • Obstruction: • Atherosclerosis ❖ Immune system involvement causing plaque buildup in artery walls ❖ Plaque buildup around blood clots ❖ Plaque buildup that obstructs blood flow through the vessel • Aortic stenosis ❖ Narrow aortic valve opening ❖ Pressure abnormalities of the left atrium leading to blood flow restriction through the aorta ❖ No common symptoms felt until the blood flow is significantly reduced ❖ Symptoms U Breathlessness U Angina with chest tightness and sensation of pressure U Syncope U Palpitations U Difficulty with mild exertion U Heart murmur

Pulmonary causes of chest pain Certain immune system and genetic disorders cause connective tissue disorders: • Ankylosing spondylitis • Dermatomyositis • EhlerseDanlos syndrome • Marfan syndrome • Rheumatoid arthritis • Pneumothorax ❖ Three types: primary spontaneous, secondary spontaneous, and traumatic ❖ Commonly called a collapsed lung ❖ When air gets into the pleural space of the lungs, and the pressure causes the lung to partially or fully collapse on itself and put pressure on the heart ❖ Primary spontaneous pneumothorax U Cause unknown U Patients ages 15e35 U Patients have no known history of lung disease U Occurs commonly in tobacco or cannabis smokers

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Chapter 4 Chest pain

•

•

•

•

❖ Secondary spontaneous pneumothorax U Asthma U Chronic obstructive pulmonary disease U Cystic fibrosis U Dyspnea U Lung infections: tuberculosis (TB) and pneumonia U Lung cancer U Pulmonary fibrosis U Sarcoidosis U Thoracic endometriosis Traumatic pneumothorax ❖ Impact U Blunt trauma damaging the chest wall and pleural space ❖ Fracture U Broken rib bone puncturing the chest wall and damaging the lung tissue ❖ No noticeable wound U Trauma from an explosion U In scuba divers forces from different pressures causing damage to the lungs U Catheter insertion into a vein in the chest while taking a sample of lung tissue Tension pneumothorax ❖ Any pneumothorax can transform to this ❖ Leak in the pleural spaces U Air becomes trapped and cannot be released during an exhale U Increased air pressure becomes life threatening and needs emergency attention Pleurisy ❖ Inflammation of the lung pleura and inner chest wall ❖ Effusion as accumulation of fluid in the pleural layers ❖ Common causes U Cancer U Congestive heart failure U Embolism U Various infections Sarcoidosis (Lim, W.S., S.V. Baudouin, R.C. George, A.T. Hill, C. Jamieson, I. Le Jeune, et al. “British Thoracic Society Guidelines for the Management of Community-Acquired Pneumonia in Adults: Update 2009.” Thorax 64 (Suppl III) 2009: 1e55. US Centers for Disease Control and Prevention. “Pneumococcal Vaccination.” December 10, 2015. ):

Chapter 4 Chest pain

❖ The cause is unknown ❖ Granulomas form in organs and on the skin causing inflammation ❖ Triggered by immune system response to viruses, bacteria, fungi, or various natural and synthetic chemicals ❖ Symptoms are more common in: U women than in men, U in the United States, people of African American descent, U those with a close family history, U people between the ages of 20 and 40. ❖ The body organs commonly affected U Brain U Eyes U Heart U Liver U Lymph nodes U Lungs U Skin U Spleen ❖ Disease affects organ systems and commonly the lungs and skin ❖ Lung symptoms include: U dry unproductive cough, U shortness of breath with wheezing, U sternal chest pain. ❖ Skin symptoms can include: U skin rashes and sores, U hair loss and pattern baldness, U raised scars. • Pulmonary TB ❖ Caused by Mycobacterium tuberculosis ❖ Airborne communicable disease ❖ Develops slowly ❖ Miliary TB is an advanced development into the bloodstream to infect other organ systems ❖ The main symptoms U Chest pain U Alternating fever and chills U Night sweats U A chronic productive cough with bloody sputum that becomes more persistent over time and gets worse U Dyspnea with exhaustion and chronic fatigue U Nausea and vomiting with lack of appetite leading to severe weight loss

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Chapter 4 Chest pain

Other causes of chest pain Other causes of chest pain include lung cancer, psychological factors, and gastrointestinal disease. • Lung cancer: ❖ Commonly, lung cancer may not become apparent until the condition has developed to a serious stage and perhaps metastasized to affect other organ systems. Symptoms include: U voice hoarseness, U shortness of breath with wheezing, U tiredness and weakness, U chest pain, U recurring bronchitis and pneumonia, U a productive cough with bloody sputum that becomes more persistent over time and gets worse. • Psychological factors: ❖ These are thought to be more common in women than in men, who may suffer more from direct heart attacks than women. ❖ Anxiety chest pain U Develops while at rest U Remains in the chest U Develops quickly and then fades somewhat rapidly U General symptoms are a squeezing, heavy pressure ❖ Physical reactions and health conditions that result U Coronary artery spasms and coronary microvascular resistance U Elevations in blood pressure U Esophageal dysmotility U Increased heart rate U Increased O2 demand in the heart U Hyperventilation • Gastrointestinal disease ❖ Burning or sharp chest pain ❖ The intensity of pain fluctuates or can be relieved by inhaling deeply ❖ Pain sensation appears closer to the surface of the skin ❖ Pain that goes away with body position changes ❖ Esophageal spasms and narrowing U Tightening sensation in the esophagus causes pain in the area of the middleeupper back U Difficulty swallowing ❖ Gastritis U Aching pain between meals when the stomach is empty

Chapter 4 Chest pain

❖ Gastroesophageal reflux U Chest pain concentrated in the epigastric region U Severe chest pain when taking a deep breath or coughing U Burning sensation in the throat with sour taste in the mouth U Burning sensation in the chest and stomach with gas reflux and burping U Chest pain while bending over and lying down U Chest pain is relieved by straightening the body if lying down, sitting, or standing ❖ Hypochondrial pain after a meal caused by gallstones ❖ Inflammation of the pancreas ❖ Inflammation of the intercostal muscle tissue and cartilage caused by shingles direct injury or bruising ❖ Fibromyalgia pain points ❖ Stomach ulcer with burning pain when the stomach is empty and relief with food ingestion

Further reading Alkhatatbeh MJ, Amara NA, Abdul-Razzak KK. Association of 25-hydroxyvitamin D with HDL-cholesterol and other cardiovascular risk biomarkers in subjects with non-cardiac chest pain. Lipids Health Dis. 2019;18(1):27. https:// doi.org/10.1186/s12944-019-0961-3. Published 2019 Jan 26. Buleu F, Sirbu E, Caraba A, Dragan S. Heart Involvement in Inflammatory Rheumatic Diseases: A Systematic Literature Review. Medicina (Kaunas). 2019;55(6):249. https://doi.org/10.3390/medicina55060249. Published 2019 Jun 6. Erem AS, Krapivina A, Braverman TS, Allamaneni SS. Serratia Liver Abscess Infection and Cardiomyopathy in a Patient with Diabetes Mellitus: A Case Report and Review of the Literature. Am J Case Rep. 2019;20:1343e1349. https://doi.org/10.12659/AJCR.918152. Published 2019 Sep 11. Faramand Z, Frisch SO, DeSantis A, et al. Lack of significant coronary history and ECG misinterpretation are the strongest predictors of undertriage in prehospital chest pain. J Emerg Nurs. 2019;45(2):161e168. https://doi.org/ 10.1016/j.jen.2018.10.007. Iftikhar H, Saleem M, Kaji A. Pernicious Anemia Presenting as Non-ST-elevated Myocardial Infarction and Depression. Cureus. 2019;11(6):e4870. https:// doi.org/10.7759/cureus.4870. Published 2019 Jun 10. Kisely SR, Campbell LA, Yelland MJ, Paydar A. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev. 2015;2015(6): CD004101. https://doi.org/10.1002/14651858.CD004101.pub5. Published 2015 Jun 30. Kwon SW, Kim JY, Suh YJ, et al. Prognostic Value of Elevated Homocysteine Levels in Korean Patients with Coronary Artery Disease: A Propensity Score Matched Analysis. Korean Circ J. 2016;46(2):154e160. https://doi.org/ 10.4070/kcj.2016.46.2.154.

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Liao J, Wang J, Liu Y, Li J, Duan L. Transcriptome sequencing of lncRNA, miRNA, mRNA and interaction network constructing in coronary heart disease. BMC Med Genomics. 2019;12(1):124. https://doi.org/10.1186/s12920-019-0570-z. Published 2019 Aug 23. Madonna R, Balistreri CR, De Rosa S, et al. Impact of Sex Differences and Diabetes on Coronary Atherosclerosis and Ischemic Heart Disease. J Clin Med. 2019;8(1):98. https://doi.org/10.3390/jcm8010098. Published 2019 Jan 16. Park JY, Oh S, Han YM, et al. There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis. Medicine (Baltimore). 2019;98(26):e15884. https://doi.org/10.1097/ MD.0000000000015884. Tetta C, Moula AI, Matteucci F, et al. Association between atrial fibrillation and Helicobacter pylori. Clin Res Cardiol. 2019;108(7):730e740. https://doi.org/ 10.1007/s00392-019-01418-w. € ller SE, et al. Non-cardiac chest pain patients in the Wertli MM, Dangma TD, Mu emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One. 2019;14(2):e0211615. https:// doi.org/10.1371/journal.pone.0211615. Published 2019 Feb 1.

5 Dyspnea and orthopnea Chapter Objectives 1. to discuss the causes of dyspnea and orthopnea; 2. to describe the etiology and symptoms of congestive heart failure and pulmonary edema; 3. to describe the complications associated with dyspnea; 4. to describe the complications associated with orthopnea; 5. to list the questions for patients for the inquiry; 6. to list diagnosing guides according to Chinese medicine and Western medicine for the physical examination; 7. to point out possible signs and symptoms and other guidance perspectives for diagnosis; 8. to list the types of treatments patients may undergo in Western medicine.

Causes Fluid retention in the legs and abdomen normally is redistributed to the chest while lying down flat; some of the fluid diffuses into the chest area. This redistribution of fluid is normal in all people; however, pathology is behind the accumulation of fluid in congestive heart failure, pulmonary edema, asthma, and sleep apnea.

Congestive heart failure and pulmonary edema In congestive heart failure, the heart is weak and cannot pump sufficient blood throughout the vessels, which affects the lungs as well. Two characteristic symptoms are palpitations and flash edema. The left ventricle pressure is elevated, causing the pressure to transmit backward through the pulmonary veins to the alveolar capillaries. Capillary pressure then becomes elevated, causing the leakage of excess fluids. Excess fluid can accumulate in the lower legs and in the lungs. Pulmonary edema is a life-threatening condition often seen in Inquiry, Treatment Principles, and Plans in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817616-0.00005-8 Copyright © 2020 Elsevier Inc. All rights reserved.

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Chapter 5 Dyspnea and orthopnea

heart failure. Over time, with debilitation, the lungs collect fluid and the alveoli are damaged. Symptoms include difficulty in breathing while lying flat, with coughing and wheezing; waking up severely short of breath; weight gain due to fluid accumulation; fatigue; and swelling of the legs. The two common heart diseases associated with these symptoms are: • acute coronary syndrome; • acute stress cardiomyopathy. The three common pulmonary diseases associated with these symptoms are: • cardiac pulmonary edema; • noncardiac pulmonary edema; • asthma.

Dyspnea Dyspnea is a condition identified in heart failure. It is characterized by an uncomfortable sensation in the chest while breathing that occurs after lying down and is relieved with head elevation and two or three additional pillows.

Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea is a condition in patients with left and right ventricular heart failure and increased pulmonary fluid pressure. The patient is suddenly awakened while sleeping in a prone or supine position. It is characterized by: • a decrease in lung ventilation capacity, such as with pleural effusion in the interstitial spaces around the alveoli, causing stimulation of the J receptors of the vagus nerve and then activation of the HeringeBreuer reflex, causing rapid, shallow breathing; • an acidebase imbalance, hypoxia, anemia, and oxygen deficit; • complications such as asthma, chronic obstructive pulmonary disease (COPD), and congestive heart failure, which can cause airway resistance due to decreased bronchial flow or systemic edema.

Orthopnea Orthopnea is a symptom of congestive heart failure with failure of both ventricles and increased pressure from fluid through the pulmonary circulation. It is characterized by shortness of breath

Chapter 5 Dyspnea and orthopnea

during low-impact activities or at rest. If in a prone or supine lying position, the patient must sit up or stand up for relief. Two symptoms of orthopnea include: • platypnea, shortness of breath while standing; • trepopnea, shortness of breath while lying on the side. Three variations of orthopnea include: • cardiac orthopnea, left- and right-sided congestive heart failure; • gestational orthopnea, heart failure, cardiomyopathy, and edema due to red blood cell lysis during pregnancy; • pediatric orthopnea, sudden infant death syndrome or asthma due to sleeping position. Orthopnea causes include: • heart disease; • angina pectoris; • ascites; • upper respiratory tract infections; • fear and anxiety; • diaphragm paralysis; • obesity; • emphysema; • pneumonia; • COPD; • pulmonary edema; • pleural effusion.

Inquiry and examination of dyspnea and orthopnea in western medicine and traditional Chinese medicine Inquiry Questions should be nonleading. Breathing: 1. Have you experienced any difficulty in breathing? 2. What was happening at the onset of breathing difficulties the first time you noticed? 3. What activities do you do that make breathing difficult now? 4. Do you notice breathing difficulties when you stand, sit, lie down, or in slow/moderate/fast-moving activities? 5. Have you developed a cough with breathing difficulty? 6. What other symptoms do you notice with the breathing difficulty? Activities of daily living:

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Chapter 5 Dyspnea and orthopnea

1. Describe activities that you are limited in your ability to do right now? 2. Describe activities that are no longer possible to do right now? 3. Describe any activities that require assistance from others, to do for you or to assist in right now? 4. How many minutes of activity can you accomplish before your breathing becomes difficult? 5. Are eating and drinking habits affected because of breathing difficulties? Sleep quality: 1. How many hours per night is normal for you to spend sleeping? 2. How long has sleeping been difficult for you? 3. How many hours per night do you sleep now? 4. Are you ever abruptly awakened because of changes in breathing? 5. Are you able to sleep flat or do you need to sit up? 6. Do you need two or three pillows to elevate your head when sleeping flat or sitting up? 7. When you elevate with more pillows, do you feel better than without the pillows? 8. Are you using a breathing device while sleeping, such as CPAP, BiPAP, etc.? Physical appearance: 1. Have you noticed any rapid weight gain over a short period of time? 2. Have you noticed any areas of edema in the lower legs? 3. Have you noticed any distended neck veins?

Physical examination In Chinese medicine, dyspnea and orthopnea involve a difficulty in inhaling and both are classified as breathlessness. The pathology mainly involves difficulty in inhaling, most likely as a failure of the kidneys to grasp the qi. Tongue and pulse examination may be, but is usually not, a significant method to determine diagnosis. Pulse Lung qi Failure of kidney to grasp qi

Weak Deep and weak

Chapter 5 Dyspnea and orthopnea

• The differentiation is qi deficiency. • Tongue may be pale, often with tooth marks. Pulse: In Western medicine, the pulse is generally absent. In Chinese medicine, the pulse is generally empty and weak. Common: • Qi deficiency • Weak or absent pulse • Hyperactive kidney • Thread pulse • Dampness and phlegm • Rolling pulse Auscultation: • First palpate the apical impulse for left ventricular enlargement or hypertrophy. • Listen for an early sign of hypertension, the fourth heart sound (S4), which indicates left atrium overwork. • Listen for underlying sign of heart disease, the third heart sound (S3), which indicates left ventricular malfunction. Pathology: • Regurgitation may be heard at the aortic position in aortic dissection. • A pericardial friction rub may be heard in pericarditis. • A midsystolic click or late systolic murmur may be heard in mitral valve prolapse. Blood pressure: This is taken in sitting, standing, or supine position and readings indicate the stage of hypertension.

Diagnosis • Determine whether the patient can sleep while lying flat or needs to elevate the head and the nature of the shortness of breath. • Determine whether the patient can sleep with or without pillows. If pillows are needed, determine how many, usually up to two or three or more. The number of pillows used can be consistent with worsening heart failure and need for hospitalization. • Determine the cause or concomitant symptoms consistent with heart failure and respiratory symptoms, including sleep apnea, bronchitis, asthma, etc., through complete physical examination and diagnostic workup.

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Chapter 5 Dyspnea and orthopnea

• Gather results of any diagnostic workup results and make future plans for follow-up, including pulmonary function testing, sleep studies, and echocardiogram. Congestive heart failure signs: • Orthopnea • Dyspnea on exertion • Decreased exercise tolerance • Distended neck veins (RV sign) • Heartbeat uneven and pulse fast paced • Crackles on lung auscultation • Swelling over the liver area or abdomen Pulmonary edema signs: • Increased weight gain • Productive cough with expectoration of froth or bloody tinge • Chest discomfort with palpitations • Wheezing • Hemoptysis and dizziness • Exercise-induced dyspnea • Orthostatic dyspnea (dyspnea while lying down) Restrictive cardiomyopathy: • Distended neck veins • Abdominal distension around the liver • Lung crackles • Faint heart sounds • Lower leg edema • Paroxysmal nocturnal dyspnea with bed elevation and two or three pillows Pericardial effusion: • Right heart failure • Hypotension • Cardiac tamponade • Distended neck veins • Dyspnea on exertion • Breathing discomfort while lying down • Jugular venous pressure elevated to 8 cm • Respiration >25 • Pulse >120 • Blood pressure (BP)