In this blog post, let’s explore the basics of History taking in medicine ). Read this post to understand the very basics: cardiac History taking 101. I will regularly update the post with new details. So subscribe to stay on top of the changes!
CVS Patient History Proforma
- Demographic details
- HOPI:
- Ask about the five cardinal symptoms: Dyspnea, Chest pain, Syncope, Palpitations, and Pedal Edema.
- cough, hemoptysis
- features of right heart failure: Pedal edema, ascites, decreased urine output, RUQ pain (due to congestive hepatomegaly)
- features suggestive of infective endocarditis and its complications (stroke/TIA, hematuria)
- Past History: ask about the past History of fever with joint pain (rheumatic fever), cyanotic spells relieved by squatting (congenital heart disease), any heart surgeries, etc.
- Personal History: IV drug abuse (if suspecting IE), etc.
Cardinal Symptoms
the cardinal symptoms that need to be elicited or asked are dyspnoea, pedal edema, Chest pain, palpitations, and syncope.
Dyspnea
How do we differentiate between cardiac dyspnoea and pulmonary dyspnoea?
What is NYHA grading?
NYHA Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
NYHA Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
NYHA Class IV: Unable to carry on any physical activity without discomfort. Symptoms are present even at rest, with increased discomfort with any physical activity.
Chest Pain
SOCRATES: Site, Onset, Character, Radiation, Associated with, Time course, Exacerbating and relieving factors, severity
Before we go any further, we need to look at the causes of chest pain:
Types of Cardiac Chest Pain with Differentials
- Anginal chest pain: Ache or dull discomfort, felt diffusely in the center of the anterior chest wall, lasting <10 minutes. Not affected by inspiration. It can have triggers and be relieved by rest and nitroglycerine.
- Unstable angina‐ angina of abrupt onset or of increasing severity, duration, and frequency. It may occur with minimal exertion or at rest.
- Nocturnal/decubitus angina‐ indicates severe coronary artery disease.
- MI: Prolonged anginal symptoms. It may be associated with autonomic symptoms,
especially in inferior wall MI. - Pericarditis: Sharp chest pain exacerbated by inspiration.
- Dissection: Abrupt onset of very severe, tearing chest pain that can radiate to the
back and is often associated with profound autonomic symptoms. - Angina equivalent‐ symptoms of myocardial ischemia other than chest pain, like
dyspnoea, fatigue, and syncope that are relieved by NTG
Edema
Location, Duration, unilateral vs bilateral, present till what level (example: up to the knee, etc), relieving factors
| Unilateral Pedal Edema | Bilateral Pedal Edema |
|---|---|
| Deep Vein Thrombosis Lymphoedema Soft tissue infection Trauma Immobility due to hemiplegia, etc | Heart Failure Chronic Venous insufficiency Hypoproteinemia: Nephrotic syndrome, Kwshiorkar disease Lymphatic obstruction due to pelvic tumor, filariasis Drugs such as amlodipine, NSAIDs, fludrocortisone |
Syncope
Transient loss in consciousness due to cerebral hypoperfusion.
Palpitations
It is an abnormal awareness of one’s heartbeat. At rest, it is more likely due to arrhythmia. Palpitations on exertion are likely due to regurgitant lesions such as AR or MR.
Both AR and MR might have palpitations as complaints, but dyspnea occurs much later than palpitations in AR. In the case of MR, they occur almost at the same time.
There are a few more points to note
- Features suggestive of left heart failure: consider MI, Hypertension, Valvular heart disease, myocarditis, Arrhythmias
- Features suggestive of Right Heart Failure include Cor pulmonale, ASD, and Pulmonary stenosis.
- Biventricular failure‐ consider High output states (esp Anaemia in failure), Left heart failure
- Global dysfunction‐ Cardiomyopathy, Myocarditis
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