Chief Complaint
Elicit the patient's chief complaint.
History of Presenting Illness (HPI)
Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.
Chest Pain or Discomfort
- Is it exertional, positional, pleuritic, tender, or does it occur at rest?
- Exertional
- Chronic, stable angina pectoris
- LVOTO (left ventricular outflow tract obstruction, e.g. AoS, HOCM)
- Pulmonary HTN
- Positional
- Pericarditis
- Angina decubitus
- GI: GERD, Pancreatitis
- Pleuritic
- Pericarditis
- Mitral valve prolapse
- Pneumonia
- Pulmonary embolism
- Pneumothorax
- Pleurodynia/pleurisy
- Resting
- Acute coronary syndrome
- ST elevation myocardial infarction
- Non-ST elevation myocardial infarction
- Unstable angina
- Aortic dissection
- Mitral valve prolapse
- Early morning
- Variant (Prinzmetal) Angina
- Other (Non-cardiac-rule out life-threatening causes first)
- GERD
- Esophageal spasm
- Peptic ulcer disease
- Costochondritis
- Herpes zoster
- Pancreatitis
- If of ischemic origin, often described as:
- "Like an elephant sitting on my chest"
- "Like a pressure"
- "Like a burning sensation" (don’t be fooled, burning ≠ GI)
- "Like a choking in my throat"
- If previous CAD Hx, is it the same as previously.
- If of ischemic origin, often brought on by the four E's:
- Exercise
- Canadian Cardiovascular Society Classification of Angina
- Grade 1: No angina with ordinary physical activity
- Grade 2: Slight limitation of ordinary activity
- Grade 3: Marked limitation of ordinary physical activity
- Grade 4: Inability to carry on any physical activity or angina syndrome may be present at rest
- Emotional stress
- Exposure to hot or cold
- Eating a heavy meal
- Note: Cardiac transplant patients do not feel ischemic pain because of denervation of donor heart
- Duration
- Angina usually lasts < 2-10min
- Myocardial infarction has a variable duration, usually longer than 30min
- Aggravating/Relieving factors:
Angina
- Relieved by rest and nitroglycerin
- Unstable angina: increase in frequency or severity compared to baseline, chest pain at rest, and any new-onset chest pain
- Minimal Canadian Cardiovascular Society Classification (CCSC) Class III see above
Myocardial infarction
- Unrelieved by rest or nitroglycerin
- Patient may report nausea/vomiting, diaphoresis, SOB, fatigue and radiation of pain to jaw, left arm, or in bilateral arms
- see Evidence Based Approach
Pericarditis
- Aggravated by deep breathing, rotating chest, or supine position
- Relieved by sitting up and leaning forward
Dyspnea
- Cardiac vs. Pulmonary Dyspnea
- Cardiac
- Sudden onset (MI, flash pulmonary edema)
- Associated with CP and/or palpitations
- Associated with bilateral pedal edema
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pulmonary
- Sudden (PE, pneumothorax, anaphylaxis) or chronic (COPD, asthma)
- Pulmonary sources: associated with unilateral leg swelling, posterior tenderness, tachycardia, immobility, hemoptysis, previous DVT, or malignancy
Fatigue
- As congestive heart failure (CHF) worsens, fatigue may replace dyspnea as the major complaint
Cough
- Cough due to cardiac disease is often dry, non-productive, and occurs first when lying flat and nocturnally.
Palpitations
- Have the patient tap out the beat with his/her hands. Is it a fast flutter? Is it a slow pounding? Is it an occasional missed beat?
Pre-Syncope/ Syncope/ "Dizziness"
- What type is it?
- Neurocardiogenic (vasovagal) – from extra PNS output
- Prolonged standing
- Situational
- Shaving
- Tight collar
- Head turning
- Urinating/ coughing/ defecating (Valsalva)
- Associated with prodrome (nausea/diaphoresis)
- Orthostatic hypotension – from lack of SNS output
- Over-medication (beta-blockers, calcium channel blockers, other anti-hypertensives)
- Dehydration
- Blood loss
- Diabetes mellitus
- Anemia
- Peripheral neuropathy
- Older age
- Arrhythmia related
- Sudden onset with no prodrome
- Seizure related
- Valvular related
- Previously known pathology
- CNS Related
Additional symptoms
- Edema/weight gain
- Intermittent Claudication
- Nausea/Vomiting
- Diaphoresis
Note: Women/elderly patients present differently when it comes to cardiovascular disease
Past Medical History (PMHx)
- CAD (Angina or MI)
- TIA or stroke
- HTN, diabetes mellitus, dyslipidemia
- PVD
- Anxiety
- Arrhythmias
- A-fib, WPW, SVT, Pacemaker
- Valvular Abnormalities
- History of rheumatic fever
- Major hospitalizations/surgeries
- Recent dental work, previous pregnancies
- History of DVT or PE
Family History (FmHx)
- Cardiovascular disease with age of onset and patient outcomes
Family history only positive if first degree relative who is: - Male and event occurs before age of 55
- Female and event occurs before age of 65
- Genetic and/or congenital abnormalities
- Marfan syndrome
- Connective tissue diseases
- Abdominal Aortic Aneurysm
- Arrhythmias
Social History (SocHx)
Specifically ask about:
- Stressors
- Diet
- Frequency and use of caffeinated beverages
- Alcohol
- Fatty foods
- GERD producing foods: Citrus fruits, caffeine, chocolate, spicy foods, etc.
- Occupational exposures
- Drilling
- Mining
- Mould
- Smoke
- Sound
Substance Use History (SubHx)
Medications
Gather complete list, including particularly relevant drugs such as:
- Antiplatelets: ASA, Clopidogrel (Plavix),Ticagrelor, Aggrenox, Prasugrel
- Anticoagulants: Warfarin, Pradaxa, Rivaroxaban, Apixiban
- Nitroglycerin spray/patch
- Beta blockers: Metoprolol, Bisoprolol, Carvedilol
- Calcium Channel Blockers: Non-dihydropuridines, Dihydropuridines
- Antiarrhythmics:Propranolol, Amiodarone
- Statins: Atorvastatin (Lipitor), Rosuvastatin (Crestor), Ezetrol
- Digoxin
- Antipsychotics (long QT interval)
Allergies
Note allergies and ensure they concord with those listed in the EMR
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
References
- 3. Andreoli, TE., Benjamin, IJ., Griggs, RC., and Wing, EJ. Cecil Essentials of Medicine, 8th edition. Section III: Cardiovascular disease. Philadelphia. PA. Saunders Elsevier; 2010 : 22-186
- Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th edition. Head and Neck chapter. Philadelphia. Lippincott Williams & Wilkins; 2007.
- McGee S. Evidence based physical diagnosis, 2nd ed. St. Louis, MO : Saunders Elsevier; 2007 : 210.