Download to notes on taking a cardiovascular history.

Taking a Cardiovascular History
•
Introduce yourself to the patient and confirm their name, date of birth and age
Ø Try to use their name throughout the consultation to help build rapport (and impress markers)
Ø In an OSCE, if there is hand gel anywhere in the station it’s probably best to use it
• Presenting complaint
Ø Establish what the patient perceives to be the problem (there may be more than one symptom)
Ø NB// patients presenting with hypertension, a heart murmur or an abnormal ECG may not actually
have any symptoms!
• History of presenting complaint
Ø Allow the patient to explain what’s happened in their own words before you start asking questions
Ø Key cardiovascular symptoms to ask about include:
§ Chest pain
§ Breathlessness, PND and orthopnoea
§ Palpitations
§ Syncope or presyncope
§ Ankle oedema
§ Fatigue
§ Intermittent claudication
Ø Try to build up a detailed timeline of symptoms and their progression in your mind
• Past medical history
Ø History of angina or previous MI – including investigations and interventions e.g. PCI, CABG
Ø History of other cardiovascular problems e.g. TIA, stroke, peripheral vascular disease
Ø Hypertension à risk factor
Ø Hypercholesterolaemia à risk factor
Ø Diabetes à risk factor
Ø Thyroid disease can cause arrhythmias e.g. AF
Ø Renal disease e.g. glomerulonephritis can cause hypertension
Ø Amyloidosis can cause restrictive cardiomyopathy
Ø Childhood illnesses e.g. rheumatic fever can cause valve disease, especially mitral stenosis
Ø Asthma contraindicates the use of beta blockers
Ø Any other problems requiring a GP appointment/hospital admission or causing concern
• Drug history
Ø Cardiac drugs
§ What they take currently: drugs, doses, routes of administration and timings
§ What they’ve tried in the past and why it was stopped (was there an adverse reaction?)
§ Antihypertensives may cause postural hypotension, syncope and fatigue
§ Digoxin causes characteristic ECG changes
Ø Thyroxine can cause arrhythmias e.g. AF
Ø Psychiatric medications: TCAs and typical antipsychotics can prolong QT interval
Ø Antibiotics e.g. macrolides and antifungals e.g. ketoconazole can prolong QT interval
Ø Beta agonists will counteract the effects of any beta blockers given
Ø OCP can increase risk of cardiovascular events and DVTs
Ø Over-the-counter medications:
§ Herbal remedies may contain generally dodgy stuff
§ NSAIDs can increase cardiovascular risk, particularly in the elderly
§ Nasal decongestant sprays contain adrenaline
Ø Allergies: document nature and severity of any reactions
• Family history
Ø History of MI or stroke in any relatives before the age of 65 à risk factor
Ø Sudden deaths, especially in younger relatives, could indicate arrhythmia or cardiomyopathy
Ø Congenital heart disease
Ø Other vascular problems e.g. DVT, peripheral vascular disease, Marfan’s syndrome
• Social history
Ø Occupation
§ Organic solvent exposure can predispose to arrhythmias and cardiomyopathy
§ Vibrating tools can cause Raynaud’s phenomenon
§ Cold exposure generally worsens angina and Raynaud’s
§ Deep sea diving can lead to formation of emboli
Ø Living arrangements
§ Ask who is at home with them and assess their social support network
§ Ask about any adaptations around the house e.g. stairlifts, handrails
Ø Assess functional and social impact of illness e.g. on work, hobbies, socialising, relationships
Ø Alcohol (units per week) can cause hypertension, palpitations, AF and dilated cardiomyopathy
Ø Smoking (pack years) a major cardiovascular risk factor
Ø Illicit drugs
§ Cocaine can cause coronary artery spasms
§ Intravenous drug use can cause endocarditis and valve disease (classically TR)
Ø Other substances
§ Caffeinated drinks such as tea, coffee and cola can cause tachycardia and palpitations
• History: chest pain
Ø SOCRATES: site, onset, character, radiation, associated symptoms, timing, exacerbating and
relieving factors (did GTN help?), severity
à you need to work out whether the pain is cardiac, pleuritic, oesophageal or musculoskeletal
à cardiac chest pain is classically central and crushing: it may radiate to the left arm, neck,
jaw, teeth, back or epigastrium, and may be associated with autonomic symptoms such as
breathlessness, sweating, nausea and anxiety. It is brought on by exercise, cold weather,
strong emotions and large meals, and relieved by rest and GTN spray.
Ø Ask about history of hypertension, angina or other heart problems
Ø Assess cardiovascular risk
Ø Ask about symptoms of potential non-cardiac causes
§ Respiratory: PE, pneumonia, pneumothorax
§ GI: GORD, oesophageal spasm
§ Musculoskeletal: muscle sprain, costochondritis, rib fractures, radiculopathy, fibromyalgia
§ Psychogenic: panic attack, somatisation disorder
• History: palpitations
Ø Define what they mean by “palpitations”
Ø Ask them to tap out the rate and rhythm of their heartbeat during an episode
Ø Ask about onset, duration, triggers, exacerbating and relieving factors (tried Valsalva?), and
associated symptoms such as chest pain, breathlessness, syncope (indicates VT) or anxiety
Ø Ask about history of hypertension, angina or other heart problems
Ø Ask about symptoms of potential non-cardiac causes
§ Endocrine: hyperthyroidism
§ Psychogenic: anxiety disorders
• History: intermittent claudication
Ø SOCRATES: site (location is important), onset (claudication distance), character, radiation,
associated symptoms (including skin changes in the legs, impotence, and other cardiovascular
problems), timing (pain at rest or at night indicates critical ischaemia), exacerbating and relieving
factors (does rest or hanging foot over the edge of the bed help?), severity
à you need to work out whether the pain is due to arterial, venous and/or neurological disease
Ø Ask about history of hypertension, angina or other heart problems
Ø Ask about symptoms of potential non-arterial causes
§ Venous: chronic venous insufficiency, DVT
§ Neurological: diabetic neuropathy, spinal stenosis causing pseudoclaudication
(associated with back pain and neurological symptoms, relieved by bending forwards)
• CARDIOVASCULAR RISK FACTORS
Ø Non-reversible: age >50, male gender, PMHx of MI/stroke, FHx of MI/stroke before age 65
Ø Reversible: hypertension, hypercholesterolaemia, hyperinsulinaemia/diabetes mellitus
Ø Lifestyle: smoking, abdominal obesity, sedentary lifestyle
Ø ?? others: inflammatory and thrombotic markers, homocysteine, infections e.g. C. pneumoniae
© Laura Jayne Watson 2011