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pulmonary hemodynamic events in patients without chronic obstructive pulmonary disease and offers a fair estimation of pulmonary venous and arterial pressures. Unfortunately, the pulmonary vascular distribution of patients with chronic obstructive pulmonary disease may be substantially altered. This complicates roentgenographic assessment.

      2.3 Physiological Values and Characteristics Considered for Clinical Examination

      Apart from analyzing the symptoms and manifestations in the face, the physician or cardiologist examines several physiological values as well as characteristics to detect the presence of heart disease. This section briefly describes the physiological attributes/characteristics and values that aid the physician or cardiologist in diagnosing heart disease.

      2.3.1 Exercise Capacity

Exercise capacity, also known as cardiorespiratory endurance, is the total amount of physical effort that a person can bear without discomfort. A precise evaluation of workout capacity requires the patient to exert maximal physical effort for an adequate enough time to reflect the stable effect on the circulation. The exercise capacity evaluation is one of the key characteristics for assessing the condition of the patient. Lower exercise capacity is linked with various risks including hypertension, cardiovascular disease, heart failure, etc. Many studies have shown the correlation between lower exercise capacity and acute health conditions [4]. Furthermore, the response of the cardiovascular system during exercise can identify heart diseases as well as mortality [5, 6].

      The exercise capacity of an individual can be assessed either by a face-to-face interview or by using laboratory methods based on the available facilities in the clinic. In the face-to-face interview with the patient, the cardiologist will ask about any unprecedented events experienced during various daily activities, such as walking, running, or exercise. On the other hand, the laboratory methods include multiple tests, such as an exercise stress test, a cardiopulmonary exercise test, a 6-minute walk test, a submaximal treadmill test, etc.

      2.3.2 Chest Pain or Discomfort

      Chest pain or discomfort is the most common symptom found in adults for several reasons either serious or trivial. It occurs due to many causes, such as muscle strain, peptic ulcers, gastroesophageal reflux disease (GERD), asthma, etc. The pain or discomfort generated in the chest can be an important indication of possibly genuine cardiac or cardiovascular disorders. Proper care and treatment should be done early to identify the underlying cause of the chest pain and prevent it worsening. Regular exercise and healthy eating habits can greatly avoid getting chest pain.

      Self-diagnosing chest pain based merely on symptoms is quite difficult. However, the frequency of pain and accompanying symptoms may help to shed light on the possible cause to some extent. The pain that arises from mild health issues including muscle strain, GERD, and asthma can last only for a few seconds and affect a specific point on the chest. Moreover, the pain is often relieved when the chest area is massaged, or after taking medication or a deep breath. Specifically, chest pain related to muscle strain gets better with massage and gets worse with sharp and sudden inhalation. Gastroesophageal reflux can cause chest pain which may be experienced shortly after a meal or consumption of alcohol. Sudden and intense pain that lasts longer than a few minutes can be an indicator of heart disease.

      2.3.3 Palpitations

      Palpitation generally refers to irregular and rapid heartbeats and can arise for a multitude of reasons. It can be caused by certain harmless conditions, such as strenuous exercise, lack of sleep, stress, anxiety, fear, etc., or it can be an alarming indication of certain illnesses relating to the heart, such as cardiac arrhythmia, which involve changes in heart rate and the contraction pattern. It can give the sensation that the heart has skipped, stopped, or added an extra beat, making us more aware of our heartbeat. Heart palpitations can become a significantly diagnosable characteristic in persons already diagnosed with heart failure or defective heart valves.

      2.3.4 Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea

Dyspnea is a condition where the patient suffers from shortness of breath or sometimes difficulty in breathing. Labored breathing, tightness in the chest, heart palpitations, and wheezing are often the indications of a person experiencing dyspnea. It can occur after intense exercise or from traveling to a high altitude. However, it can be directly related to severe health conditions such as pneumonia, heart failure, or low blood pressure. Dyspnea on exertion can be a normal occurrence unless it accompanies an activity that can be considered to be within the tolerance limits of the individual.

      Since dyspnea is often characterized by the subjective experience or sensation reported by the patient, it is quite distinguishable from tachypnea, hyperventilation, and hyperpnea, which refer to respiratory variations. The latter conditions exist irrespective of the patients’ subjective sensations. Tachypnea is an increase in the respiratory rate, which is indicated by rapid shallow or deep breathing, often unnoticed by the patient. Hyperventilation is the increased and rapid breathing that occurs due to an unbalance between inhalation and exhalation. The increased exhalation results in reduced carbon dioxide levels in the blood, which in turn leads to the symptoms such as dizziness, shortness of breath, etc. Hyperpnea is also a condition of deep breathing but not necessarily faster. The forced respiration causes the inhalation of an increased air volume and the respiratory rate can even stay within normal limits. This is an indication of the body’s demand for more oxygen. These medical conditions might not always be associated with dyspnea.

      The sensation of breathlessness that occurs only in the specific posture of lying down is referred to as orthopnea. It can result in tightness in the chest that makes breathing uncomfortable. However, it subsides when the patient stands upright or sits down. Still, it might be a symptom of heart or lung disease. The presence of increased heart rate, wheezing, or nausea along with orthopnea is an indicator for heart failure. A condition that is closely related to orthopnea is paroxysmal nocturnal dyspnea. It is a sensation of shortness of breath that makes the patient wake up after 1 or 2 hours of sleep. Similar to orthopnea, this condition is usually relieved after getting back to the upright position.

      Apart from the aforementioned conditions of breathing difficulties, there are two uncommon types of breathlessness: trepopnea and platypnea. Trepopnea is typically dyspnea or breathlessness in either lateral decubitus position. The shortness of breath when lying on the left side can be attributed to chronic heart diseases. On the other hand, breathlessness experienced while lying on the right side may be due to a lung disease or a major bronchus. Platypnea is the reverse condition of orthopnea. This refers to breathlessness that occurs in the upright position (sitting or standing) and gets improved when lying down.

      2.3.5 Claudication

Claudication is a pain, cramp, or sense of fatigue that results from the lower blood flow to the muscles during exercise. This affects the muscle group of the lower extremities and causes pain in the legs depending on the pace and duration of the walk. It is relieved promptly within a few minutes of rest in positions such as standing evenly on both feet. This condition can occur anywhere in the body, but is predominantly in the legs. Even though the pain is not constant and subsides with rest, it can be a symptom of peripheral artery disease.

      2.3.6 Recording History of Heart Disease

      In many heart patients, mostly adults, the heart disease or discomfort related to the heart won’t begin suddenly in a day. A detailed study about the history of any chest discomfort or heart disease experienced by the patient in the past can provide additional information about the underlying disease for the cardiologist. The history recording procedure investigates whether the patient has suffered any heart attack or coronary artery diseases, whether they have undergone any heart surgery in the past, their medication history, etc. The cardiologist will also ask when an incident happened, how it was diagnosed, about the patient’s lifestyle after that incident, etc. Furthermore, the history recording procedure will inquire into whether the patient was healthy

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