Die klinische Untersuchung – ein Auslaufmodell?

 

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Widmung

Diese Arbeit ist Herrn Professor Dr. med. Franz-Josef Kessler † (ehemaliger Chefarzt der Inneren Abteilung am Malteser-Krankenhaus Bonn), dem engagierten Kliniker und Lehrer, in Dankbarkeit gewidmet.

Zusammenfassung

Berichtet wird über eine 63-jährige Patientin, die sich wegen progredienter Dyspnoe in einer internistischen Facharzt-Praxis vorstellte. Konsultationen beim Hausarzt und einem Kardiologen sowie Aufenthalte im Akutkrankenhaus und in einer kardiologischen Schwerpunktklinik hatten keine schlüssige Diagnose ergeben. Bei der klinischen Untersuchung imponierte (neben deutlichen Beinödemen) eine ausgeprägte Halsvenenstauung im Sitzen, die Anlass zu weiterer gezielter Diagnostik war. Dabei wurde eine konstriktive Pericarditis tuberkulöser Genese festgestellt.

Die Diagnosefindung wird im Lichte einer zunehmend technisierten Medizin diskutiert, in der Anamnese und klinischer Befund kontinuierlich an Bedeutung verlieren. Ferner wird die Problematik erörtert, dass im klinischen Alltag die nicht so häufigen Erkrankungen des Myo- und Perikards mit vorwiegend diastolischer (konstriktiver oder restriktiver) Funktionsstörung der kardiologischen Routinediagnostik – mit Zentrierung auf die KHK, die Klappenfehler und die Einschränkung der systolischen Ventrikelfunktion (LV-EF) – entgehen können.

Abstract

This report describes the case of a 63-year-old female patient who presented with progressive dyspnea to a specialized internal medicine practice. Prior consultations with her primary care physician and a cardiologist followed by hospitalizations in an acute care hospital and in a specialist clinic for cardiology had not yielded a conclusive diagnosis. During the physical examination, significant bilateral lower extremity edema, as well as pronounced jugular venous distention was noted while in a seated position. This prompted further targeted diagnostic examination and testing and resulted in the final diagnosis of constrictive pericarditis of tuberculous origin.

The establishment of the diagnosis is discussed in the context of increasingly technologized medical practice, where clinical skills and the significance of the patient history and physical examination are declining. In addition, we discuss the problem of less common diseases of the myo- and pericardium with primarily diastolic (constrictive or restrictive) dysfunction being overlooked in routine cardiological diagnostic procedures, with a focus on coronary heart disease, valve disorders and the impairment of systolic ventricular function (“ejection fraction”).

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