Cardiovascular History Taking PDF

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CSEC- Cardiovascular History Taking Overview...

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Cardiovascular History Taking Introduction, Patient and Consent  Greet and introduce yourself  Explain what you are going to do and gain consent  Ask open-ended questions (Where is your pain)  Try not to use medical terms (Do you have orthopnoea) Presenting Complaint  Symptom felt by the patient and not a diagnosis  Generally ask What has brought you here today? How can I Help you? History of Presenting Complaint  How long have you had this pain?- Duration  Is the pain continuous or does it come and go? o How often do you get the pain?- Frequency o How long does it last each time?- Episodic Duration  Has anything changed over time you have had this pain  Where do you feel the pain?- Site  What is the pain like?- Character  How Severe was the pain?- Severity- scoring system  Did the pain spread anywhere- Radiation  Does anything bring the pain on, does it occur when resting?  What makes the pain worse?- Exacerbating Factors  What makes the pain better?- Relieving Factors  DO you notice anything else when you have the pain?- Nausea, Sweating?- Associated Symptoms  Enquire further about other relevant cardiovascular symptoms: Dyspnoea  Subjective feeling of breathlessness  Can be casued by many conditions including o Heart Failure o Pulmonary Disease o Pleural Effusions o Anaemia o Obesity o Anxiety  In many cases patients are comfortable at rest but become dyspnoeic on exertion.  Exertional dyspnoea is usually due to cardiac failure, chronic pulmonary disease or poor physical condition.  It is important to ask the patient about his or her ability to perform daily activities - this is a useful measure of exercise capacity and disease progression. Orthopnoea  Difficulty breathing in the lying position than when sitting upright.  The patient will describe sleeping comfortably with for example two or three pillows but become short of breath if lying flat.  It is usually associated with congestive heart failure but may occur with severe lung disease. Paroxysmal Nocturnal Dyspnoea  Sudden wakening form sleep with shortness of breath

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The patient will sometimes sit on the side of the bed to seek relief, or may occasionally even open a window to recover. Usually associated with congestive heart failure but similar symptoms may occur with asthma

Ankle Swelling  Can be due to oedema from heart failure  Such ankle oedema is usually symmetrical and worse in the evening.  If the heart failure progresses the oedema can ascend up the legs, and in severe cases to the lower abdomen/sacral areas. Palpitations  Usually taken to mean an unexpected awareness of the heartbeat.  Ask the patient to describe exactly what they noticed: o Fast o Regular/ Irregular o Skipped Beats o How long it lasted o Other symptoms? Syncope  Transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate blood flow.  Establish: o Did they lose consciousness? o Under what circumstances did this occur? o Did the patient experience any warnings? o Was recovery spontaneous or did the patient take time to recover? o Did any bystanders notice any abnormal movements? Claudication  Pain in one or both legs, usually in the calves when they walk more than a certain distance.  This distance is called the claudication distance.  A history of claudication suggests possible peripheral vascular disease with a poor blood supply to the affected limb.  Eventually, with increasing severity of disease the pain may occur at rest (rest pain). Past Medical History  Ask the patient if they have any other medical problems and specifically any Cardiovascular Problems  Have you any other medical conditions? Have you had any operations?  Afterwards ask: 'I'm going to run through a few conditions to make sure we didn't miss anything o Diabetes o Hypertension o Heart Attach (Myocardial Infarct) o Angina o Stroke  Think specifically about associated risk factors of the condition you think you are dealing with

Drug History  Are they taking any medications  Allergies to Medications? If so, enquire what type of reaction they had  Are you taking any prescribed medications  Any over the counter medications  Any herbal Medications  Any Allergies?  Any Illicit Drugs? Family History  Do any medical conditions run in your family  Ask general questions initially then target questions to specific cardiac problems.  Ask about: o Diabetes o Heart Disease o Stroke o Hypertension  Enquire further if positive family history Social History  Ask if they smoke. If so: o Cigarettes/ Cigar/ Pipe o Number a day  If they don't smoke, ask if they have ever smoked  Do they consume Alcohol, How much per week?  What is their occupation  Have their symptoms had an impact on their life?  Living Situation Review of Symptoms  Make a full review of other symptoms including: o Respiratory o Gastrointestinal o Genitourinary o Musculoskeletal o Nervous System Summary  Summarize findings to patient.  Opportunity for the patient to confirm their history and to ensure that info obtained reflects that patient's true history....