Cardiovascular history taking

Question 1

Introduction

Answer 1

Introduce yourself, confirm patient’s details (name, DOB and age)- gain informed consent (I’ve been asked by one of the docs to discuss what it is that’s brought you here today, everything said kept confidential- is it okay if we go ahead?)
* if at any stage today you feel the pain is too much, I can ask the nurse for some painkillers
HANDWASHING, PPE

Question 2

Presenting complaint

Answer 2

Open q’s- where is your pain? how can I help you today?

Question 3

History of presenting complaint

Answer 3

S- site 
O- onset
C- character
R- radiation
A- associated symptoms
T- time
E- exacerbating factors
S- severity (/10)

Question 4

History of presenting complaint- ask have they noticed any of these?

Answer 4

Dyspnoea- subjective feeling of difficulty breathing, can be caused by heart failure, pulmonary disease, pleural effusion, anaemia, obesity or anxiety

Orthopnoea- difficulty breathing while supine
Assc. w CHF or severe lung diseases

Paroxysmal nocturnal dyspnoea- sudden wakening from sleep w/ shortness of breath, CHF or astmha

Ankle swelling/oedema- HF, usually symmetrical, worse in evening- can ascend up legs, lower abdomen + sacral areas in severe cases

Palpitations- fast? regular? irregular? skipped beats? length? other symptoms, eg dysponoea chest pain syncope

Syncope- fainting, cerebral anoxia thorugh inadequate blood flow- lost consciousness? how- any warnings? spontaneous recovery? how long to? bystanders?

Intermittent claudication- pain in 1/both legs (calves) through walking- claudication distance
History of it suggests PVD, poor blood supply to affected limbs- with inc. severity it may occur at rest

Question 5

Past medical history

Answer 5

Any other medical/ CV problems in past? How’s your general health- any operations?
Not to miss anything- diabetes, HT, MI, angina, stroke?
Associated risk factors of condition you may be dealing w?

Question 6

Drug history

Answer 6

Taking any? allergies? what reactions? prescriptions, over the counter, herbal
Any illicit/recreational drugs?

Question 7

Family history

Answer 7

Any medical conditions run in the family? diabetes, ht, stroke, chd- if there is which member? age of onset?

Question 8

Social history

Answer 8

Smoker? ever smoked? what smoking? how many?
Alcohol? units?
Job?
Symptoms impacted life? mental health? social life? what are the patients Ideas Concerns Expectations

Question 9

To finish

Answer 9

Review symptoms- resp, GI, GU, MSK, Nervous
Summarise back to patient- ——— have i missed anything?
—- is a —- came into today with ——-, to complete my exam i would perform a physical exam of JVP and CXR
order full CV exam- HR BP JVP PRAECORDIUM LUNGS PULSES
potentially 12 lead ecg, treadmill, tracer or CT