History Taking

Question 0

What to ask in a cardiovascular examination?

• major symptoms
• past history
• social history
• family history
• coronary artery disease risk factors
• functional status in established heart disease

Answer 0

Major symptoms:

• chest pain/ heaviness
• dyspnoea: exertion all (note degree of exercise tolerance), orthopnoea, paroxysmal nocturnal dyspnoea
• ankle swelling
• palpitations
• syncope
• intermittent claudication
• fatigue

Past history:

• history of IHD: MI, coronary bypass grafting, rheumatic fever, chorea, STI, recent dental work, thyroid disease
• prior medical examination revealing heart disease
• drugs

Social history:

• tobacco and alcohol use
• occupation

Family history:
- MI, cardiomyopathy, congenital heard disease, mitral valve prolapse, Marian’s syndrome

Coronary artery disease risk factors:

• previous coronary disease
• smoking, HTN, hyperlipidaemia,
• family history of coronary artery disease
• DM
• obesity and physical inactivity
• male sex and advanced age
• raised homocysteine level

Functional status established heart disease
- class I = disease present but no symptoms or gains or dyspnoea during intense activity
- class II = angina or dyspnoea during ordinary activity
- class III = angina or dyspnoea during less than ordinary activity
Class iV = angina or dyspnoea at rest

Question 1

Causes (ddx) of chest pain with typical features

• cardiac pain
• vascular pain
• pleuroperiphericardial pain
• chest wall pain
• gastrointestinal pain
• airway pain
• other causes
• mediastinal pain

Answer 1

1. Cardiac pain
   - myocardial ischaemia or infarction (central, tight, heavy, may radiate to jaw or left arm)
2. Cardiac pain
   - aortic dissection (very sudden onset, radiates to the back)
   - aortic aneurysm
3. Pleuroperiphericardial pain
   - pericarditis +/- myocarditis (pleuritic pain, worse when patient lie down)
   - infective pleurisy (pleuritic pain)
   - pneumothorax (sudden onset, sharp associated with dyspnoea)
   - pneumonia (often pleuritic, associated with fever and dyspnoea)
   - autoimmune disease (pleuritic pain)
   - mesothelioma (severe and constant)
   - metastatic tumour (worse with movement, chest wall tender)

Chest walls pain

• persistent cough (worse with movement, chest wall tender)
• muscular strains (worse with movement, chest wall tender)
• thoracic zoster (severe, follows nerve root distribution, precedes rash)
• coxsakie b virus infection (pleuritic pain)
• thoracic nerve compression or infiltration (follow nerve root distribution)
• rib fracture (history of trauma, localised tenderness)
• rib tumour, primary or metastatic (constant, severe, localised)
• tietze’s syndrome (costal cartilage tender)

Gastrointestinal pain

• gastro-oesophagea reflux (not related to exertion, may worsen when patient lie down)
• diffuse oesophageal spasm (associated with dysphagia)

Airway pain

• tracheitis (pain in throat, breathing painful)
• central bronchial carcinoma
• inhaled foreign body

Other causes
- panic attack (often preceded by anxiety, associated with breathlessness and hyperventilation)

Mediastinal pain

• mediastinitis
• sarcoidosis adenopathy, lymphoma

Question 2

Questions to ask when patient with suspected angina (point out the urgent ones)

Answer 2

• can you tell me what the pain or discomfort is like? Is it sharp or dull, heavy or tight?
• when do you get the pain? Does it come out of the blue, or come on when you do physical things? Is it worse if you exercise after eating?
• how long does it last?
• where do you feel it?
• does it make you stop or slow down?
• does it it go away quickly when you stop exercising?
• !!!! Is it coming on with less effort or at rest? (Unstable angina)
• have you had angina before and is this the same?