08-09-22 - History Taking - The Cardiovascular System Flashcards
Learning outcomes
• To demonstrate an understanding of the role of a cardiovascular systems enquiry.
• To demonstrate an awareness of the causes of common cardiovascular symptoms.
• To demonstrate an awareness of risk factors for cardiovascular disease.
• To understand how different body systems can inter-relate.
What are the 6 stages of the traditional medical model?
• 6 stages of the traditional medical model:
1) History
2) Examination
3) Investigation
4) Diagnosis
5) Treatment
6) Follow up
What are the 5 stages of the Roger Neighbour Inner Consultation Model 1987?
• This model asks the same questions as the traditional method, but in a different order
• 5 stages of the Roger Neighbour Inner Consultation Model 1987:
1) Connecting
• Building rapport
• Identifying patients views beliefs and expectations
2) Summarising
• Explaining back to the patient what they have told you
• Allow for correction/development of ideas and understanding
3) Handing over
• Agreeing on doctor’s and patient’s agendas
• Involves negotiating and influencing shared management plan
• Giving ownership and responsibility of management plan to patient
4) Safety netting
• Providing advice on what to do if things get worse
• Could be a follow up, advice, or referral
• For the benefit of both doctor and patient
• Ensures ill patients stay in the medical system
5) Housekeeping
• Looking after yourself as a doctor e.g coffee or going for a walk
• Ensures you can provide a high level of care for every patient you see
What are the 7 stages for the structure of history taking?
• 7 stages of history taking:
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)
How do you start the presenting complaint section (PC) of history taking?
What do you then do?
What is it important to do when doing this?
• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?
• It is then important to get a description of symptoms from the patient
• It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest
What is it important to establish during history of presenting complaint (HPC)?
What is it important to do during this section?
How can patient conversation be facilitated?
What 2 questions should be constantly be thinking in HPC?
What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?
• During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
• Is it important to allow the patient to speak, and not jump in during this section
• Also important to facilitate the patient giving their account by asking a mix of open and close questions
* Be constantly thinking:
1) What are the possible diagnoses?
2) What else do I need to know to help decide which diagnosis is the correct one?
- Useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section:
• S – Site – location of pain
• O – Onset – when the pain started
• C – Character – shooting, stabbing, dull ache, throbbing pain
• R – Radiation – see if pain radiates away from source
• A – Associated symptoms – give examples
• T – Timing – pain worse at a particular time? Is it constant or intermittent?
• E – exacerbators/relievers – What makes the pain better/worse
• S – severity – pain on a 1-10 rating
What symptoms do we ask about in HPC when dealing with the cardiovascular system?
What should we do after asking these questions?
• We expect with the CV system that we ask about every symptom during HPC
• Symptoms we ask about:
1) Chest pain (angina)
2) Breathlessness (Dyspnoea; including orthopnoea and Paroxysmal Nocturnal Dyspnoea - PND)
3) Syncope (loss of consciousness due to lack of blood flow to brain)
4) Dizziness
5) Oedema (swelling)
6) Fatigue
7) Peripheral vascular symptoms (colour changes, cramping, pain in legs e.g intermittent claudication – muscle pain that happens when you’re active and stops when you rest)
8) Systemic upset e.g temperature, weight loss, skin changes
• After asking these questions, we can use the pneumonic SOCRATES to establish a timeline and find relievers/exacerbators)
What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?
What is the 10-part mnemonic for PMH?
• Information about previous illnesses during PMH:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion
• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke
What are some known risk factor diseases that we may want to ask about when taking dealing with past medial history on the CV system?
• Risk factor diseases to ask about for PMH in the CV system:
1) History of vascular disease e.g coronary artery, cerebrovascular, peripheral vascular
2) Diabetes
3) Hyperthyroidism
4) Renal disease
5) Hypertension
6) Hypercholesterolaemia
7) High BP
8) Previous strokes/mini strokes
9) Previous heart disease
What 4 types of drugs are considered during Drug history (DH)?
What are the 5 things considered when documenting a drug in drug history?
What must be asked regarding allergies?
What is an important allergy to keep in mind?
What is the difference between allergies and adverse effects?
• 4 types of drugs considered during drug history:
1) Prescribed medication
2) Over the counter medication
3) Herbal medication
4) Consider illicit drug use (recreational)
• 5 things considered when document a drug in drug history:
1) Name of drug
2) Dose
3) Route (e.g oral, intramuscular, per rectum)
4) Frequency
5) Duration
• We want to know why they are taking it and if they are takng it correctly
• Regarding allergies, we must ask “are you allergic to anything/any medicines that you know of?
• Elastoplast/latex allergies are important to keep note of
• Adverse effects are expected known side effects of drugs, and are not the intended therapeutic purpose of the drug
• Allergies to medicine are adverse drug reactions mediated by an immune response
• Medicine that can cause adverse effects (e.g stomach upset) can still be prescribed, but it depends on the severity of the effects.
What is the purpose of asking about family history (FH)?
What are 4 questions that may be asked?
What may be useful during this section?
What disease might we want to specifically ask about regarding the CV system?
What degree of relative are we most interested about?
What age range are we looking at?
• Asking about family history may give clues about possible genetic pre-disposition to illness
• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?
2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?
3) Do you have any children? How old are they? Are they well/any illnesses?
4) Are there any health problems that run in your family?
• We want to ask if any 1st degree relatives (parents, siblings, children) have a history of cardiovascular disease at a young age
• 1st degree male relative less than 55 years
• 1st degree female relative less than 65 years
• May be useful to draw a family tree
What are the various aspects of social history (SH) asked about?
1) Employment
• Are you working at the moment?
• May I ask what you do?
• What does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise
2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)
3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week
4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
• This is one of the most important sections, as we want to ensure the patient has access to what they need to live in their home
5) Other questions to consider:
• Exercise/diet
• Do they have any hobbies or interests?
Do they have any pets?
• Do they drive?
What is system enquiry?
What is the purpose of the system enquiry portion of an interview?
What are 7 systems that may be asked about?
What are symptoms we may look for?
• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool
• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS (respiratory) – cough, mucus, shortness off breath
3) GI – change in bowels, abdominal pain
4) GU (genitourinary) – urinary systems, change in water works, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance, changes in weight
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits, collapses
What are 3 questions we ask to address ideas, concerns, and expectations of the patient?
• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?
What is the purpose of summarising to complete a history taking?
What is important that needs to occur throughout the session?
• Summarising:
• Helps to clarify points
• May highlight questions you haven’t asked or misunderstanding
• Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
• Brings up relevant features in the remainder of history
• Brings up relevant positives/negatives from systems enquiry
• It is important to explain and gain consent for examination as appropriate
What are 4 non-modifiable risk factors for CV disease?
What are 6 modifiable factors?
What are the causes of angina from different systems?
• Cardiovascular system
• Respiratory
• Upper GI
• MS system
• Other
• Causes of angina based on systems:
• Cardiovascular causes of angina
1) Stable angina
• Chest pain that occurs with exercise (increased myocardial demand) but dissipates with rest.
• Caused by poor blood flow through blood vessels in the heart
2) Acute coronary syndromes (describes a range of conditions with sudden, reduced blood flow to the heart)
3) Pericarditis
• Inflammation of protective fluid-filled sac around the heart called the pericardium.
• Associated with infection
• Presents with acute onset of chest pain, which is usually pleuritic in nature, and can be eased by sitting up and leaning forward
• Pleurisy is the inflammation of the pleurae, which impairs lubricating function and causes pain when breathing (caused by pneumonia and other disease of the chest or abdomen)
• Pain may be anywhere over the anterior chest wall, but it is usually retrosternal (behind sternum).
• May radiate to the arm like ischaemic pain.
• Characteristic pain of pericarditis is the radiation of pain to the trapezius ridge
4) Aortic dissection
• Tear in the walls of arteries
• Can be caused by blood getting trapped between the layers of blood vessels, leading to tearing of layers
• Sudden and severe pain
• Tearing and deep pain
• Pain radiates to left shoulder/back
• Respiratory causes of angina:
1) Pulmonary embolus – pulmonary artery blockage in the lung caused by a blood clot
2) Pneumothorax – collapsed lung
3) Pneumonia – inflammation of tissue in one or both lungs usually caused by bacterial or viral infection
4) Lung cancer
5) Mesothelioma – lung cancer caused by asbestos exposure
• Upper GI causes of angina
1) Oesophageal disease
• MS system causes of angina
1) Muscle or rib injury
2) Costochondritis – inflammation of the costal cartilage where it connects to the sternum
• Other causes of angina
1) Herpes zoster – aka shingles, caused by the same virus that causes chickenpox
What is PND?
What is it caused by?
What relieves it?
What is orthopnoea?
How is it relieved?
What causes it?
How can it be measured?
• PND is paroxysmal nocturnal dyspnoea means ‘sudden night-time breathlessness’
• It is a sensation of shortness of breath that awakes the patient often after 1 or 2 hours of sleep
• PND is caused by too much fluid in the bottom of the lungs (pulmonary oedema)
• When sleeping, the fluid moves back up, causing breathlessness
• PND is relieved by sitting upright
• Orthopnoea is the sensation of breathlessness in the recumbent position
• It is relieved by sitting or standing
• Caused by increased pressure in the blood vessels of the lungs
• Can be measured through the number of pillows used at night e.g 3 pillow orthopnoea
What is oedema?
What is pulmonary oedema?
Why does oedema occur?
What is pitting oedema?
What are 3 causes of pitting oedema?
What type of oedema suggests serious underlying pathology?
What does unilateral and bilateral oedema indicate?
What are 9 causes of bilateral oedema?
What are 4 causes of unilateral oedema?
• Oedema is a build-up of fluid in the body which causes the affected tissue to become swollen
• Pulmonary oedema is the abnormal build up of fluid in the lungs
• Oedema occurs because the heart isn’t working properly as a pump to move water around the body
• Pitting oedema is when pressing on a fluid build up leaves an indentation that will refill
• Causes of pitting oedema:
1) Most commonly develops secondary to increased venous pressure
2) Reduce oncotic pressure
3) Idiopathy
• Oedema with rapid onset or deterioration or associated with marked symptoms, such as dyspnoea suggests serious underlying pathology and warrants more investigation
• Unilateral oedema tends to reflect local pathology (more concerning
• Bilateral oedema indicates a system cause
• Causes of bilateral oedema:
1) Congestive cardiac failure – heart can’t pump blood around body properly
2) Cor pulmonale – abnormal enlargement of the right side of heart as a result of disease or disease of the lungs or pulmonary vessels
3) Cirrhosis
4) Acute renal failure
5) Medication e.g channel blockers
6) Sepsis – extreme immune response to infection
7) Myxoedema - advanced hyperthyroidism
8) Pregnancy
9) Idiopathic
• Causes of unilateral oedema:
1) DVT – Deep vein thrombosis – blood clot formation in deep vein
2) Chronic venous insufficiency – leg veins don’t allow blood to flow back up to the heart
3) Compartment syndrome – increased pressure in a body part results in insufficient blood flow due to compression of neurovascular bundles
4) Retroperitoneal mass – peritoneum is the tissue that lines the abdominal wall and covers most of the organs in the abdomen
What is the CV causes of fatigue?
What is perfusion?
• CV cause of fatigue:
1) Inadequate systemic perfusion in cardiac failure (perfusion – the passage of fluid though the circulatory system or lymphatic system to an organ or tissue, usually referring to delivery of blood to a capillary bed in tissue)
2) Side effects of medication e.g beta blockers
What is the difference between left and right sided heart failure (left and right ventricular failure)?
What are causes of left-sided heart failure?
What are 3 symptoms of left sided heart failure?
What are 4 causes of right-side heart failure?
What are 2 symptoms of right-side failure?
What happens when both sides of the heart fail?
• In left side ventricular failure, the left side of the heart is weakened, which reduces its ability to pump blood into the body.
• This results in blood filling up in the pulmonary veins and lungs
• Causes of left side heat failure:
1) Coronary artery disease (most common cause)
2) Heart attack
3) Long term high blood pressure
• Symptoms of left-side heart failure:
1) Shortness of breath
2) Trouble breathing
3) Coughing (all especially during physical activity)
• In right side heart failure, the ventricle of the heart is too weak to pump enough blood to the lungs.
• This causes a build-up of blood in the veins and organs
• This increase in pressure in the veins can push fluid out into surrounding tissue
• Causes of right-side heart failure:
1) Usually develops as a result of advanced left-side failure
2) High blood pressure in the lungs
3) Pulmonary embolism
4) Lung disease like COPD
• Symptoms of right-side heart failure:
1) Build up of fluid in the legs
2) Build up of fluid in the genital area, organs or abdomen (all less common)
• When both sides of the heart fail, it is called biventricular failure
• This can cause the same symptoms as both left and right-side failure, such as shortness of breath and build-up of fluid
