Cardiovascular history (inc. general principles) Flashcards
How should you open the consultation?
- Introduce yourself – name / role
- Confirm patient details – name / DOB
- Explain the need to take a history
- Gain consent
- Ensure the patient is comfortable
What questions should you ask when taking the history of the presenting complaint?
Onset – When did the symptom start? / Was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. an inhaler
Associated features – are there other symptoms that appear associated e.g. fever / malaise
Previous episodes – has the patient experienced this symptoms previously?
What are the key cardiovascular symptoms?
Chest pain – SOCRATES
Dyspnoea – exertional / orthopnea / paroxysmal nocturnal dyspnoea
Palpitations – ask patient to tap out the rhythm
Syncope / Dizziness – postural / exertional / random
Oedema – peripheral oedema (e.g. lower limbs) / sacral oedema
Intermittent claudication – e.g. leg pain worsened on exertion / improved at rest
Systemic symptoms – fatigue / fever / weight loss / weight gain
What is SOCRATES and why is it used?
In the assessment of pain:
Site
– where is the pain
Onset
– when did it start? / sudden vs gradual?
Character
– sharp / dull ache / burning
Radiation
– does the pain move anywhere else?
Associations
– other symptoms associated with the pain
Time course
– worsening / improving / fluctuating / time of day dependent
Exacerbating / Relieving factors
– anything make the pain worse or better?
Severity
– on a scale of 0-10, how severe is the pain?
What are the relevant cardiovascular risk factors?
- Hypertension
- Smoking
- Hyperlipidaemia
- Diabetes
- Family history
What are ‘ideas, concerns and expectations’?
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
What is ‘signposting’?
Signposting involves explaining to the patient:
What you have covered – “Ok, so we’ve talked about your symptoms & your concerns regarding them”
What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
What are the relevant conditions to note in past medical history?
- Angina
- Myocardial infarction – bypass grafts / stents
- Atrial fibrillation
- Stroke
- Peripheral vascular disease
- Hypertension
- Hyperlipidaemia
- Rheumatic fever
What is the relevant drug history?
Cardiovascular medications:
- Beta blockers
- Calcium channel blockers
- ACE inhibitors
- Diuretics
- Statins
- Antiplatelets
- Anticoagulants
- Glyceryl trinitrate spray
- Other regular medications
Contraceptive pill – increased risk of thromboembolic disease
Over the counter drugs – NSAIDS / Aspirin
Herbal remedies – St John’s Wort – enzyme inducer – can affect Warfarin
ALLERGIES – ensure to document these clearly
What are the relevant family history questions to ask?
Cardiovascular disease at a young age
– myocardial infarction / hypertension / thrombophilia
Are parents still in good health?
– if deceased determine age & cause of death
Any unexplained deaths in young relatives?
– long QT syndrome / channelopathies
What are the relevant questions to ask about social history?
Smoking
– How many cigarettes a day? How many years have they smoked for?
Alcohol
– How many units a week? – type / volume / strength of alcohol
Recreational drug use
– e.g. Cocaine – coronary artery vasospasm
Diet
– Overweight? Fatty foods? Salt intake? – cardiovascular risk factors
Exercise
– baseline level of patient’s day to day activity
What are the relevant questions to ask about living situation and why?
House/bungalow?
– adaptations / stairs
Who lives with the patient?
– is the patient supported at home?
Any carer input?
– what level of care do they receive?
What questions should you ask about the activities of daily living?
- Is the patient independent / able to fully care for themselves?
- Can they manage self hygiene / housework / food shopping?
- Occupation - sedentary jobs 0 ↑ cardiovascular risk – e.g. Lorry driver
What is the systematic enquiry and what is the point of performing it??
- Involves performing a brief screen for symptoms in other body systems.
- This may pick up on symptoms the patient failed to mention in the presenting complaint.
- Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).
- Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
What are the elements of the systematic enquiry?
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers
