The Cardiac Exam: History Taking

Introduction

•     Chest pain
•     Cyanosis (turning blue)
•     Dyspnea (shortness of breath)
•     Edema (dependent - i.e. gravity edema)
•     Fainting (syncope)
•     Fatigue
•     General
•     Hemoptysis (coughing up blood)
•     Irregular heart beat

Questions for each symptom should cover the 7 classic dimensions of directed history taking:

1.     quality (q1)
2.     quantity (q2)
3.     aggravating (alleviating) factors (af)
4.     time course (t)
5.     location (l)
6.     associated symptoms (as)
7.     setting (s)

A sample list of relative questions pertaining to each symptom (including question category) is shown below.

Chest Pain

• Where is the pain (l)?
• When did the pain first start (t)?
• How long does it last (t)?
• Does the pain radiate, if so where (q2/am)?
• How often do you have the pain (q2)?
• How would you describe the pain - burning, pressing, stabbing, crushing, dull, aching, throbbing, sharp, constricting (q1)?
• Does the pain occur at rest, with exertion, with stress, after eating, when moving your arms, or during intercourse (af/s)?
• Do you have any other symptoms with the pain such as shortness of breath, palpitations, nausea, vomiting, coughing, fever, leg pain (as)?

Cyanosis (bluish color skin)

• Where is the bluish color skin?
• How long have you noticed it?
• Did is seem to happen suddenly or gradually?
• What type of work do you do?
• Does anyone else in your family has this condition?
• What makes the bluish skin color better or worse?
• Have you had any chest pain, cough, or bleeding associated with the bluish color skin?

Dyspnea (shortness of breath)

• How long have you been short of breath?
• Did the shortness of breath occur suddenly or gradually?
• Do you ever wake up at night feeling short of breath (paroxysmal nocturnal dyspnea)?
• How many pillows do you sleep on at night?
• How far can you walk before you become short of breath?
• Have you notice swelling in your legs associated with your shortness of breath?
• Have you had any chest pain associated with your shortness of breath?

Edema (dependent)

• Do you have swelling in your legs?
• When did you first notice the swelling?
• Did it appear suddenly or gradually?
• Is the swelling worse in the morning or evening?
• Does the swelling decrease after a night's sleep?
• Do you shortness of breath associated with the swelling?
• Have you noticed any change in your weight?
• Does elevating your feel make the swelling go down?
• Do you have pain in your legs associated with the swelling?
• Do both legs swell equally?
• Are you taking any medications, if so, which ones?

Fainting (syncope)

• How often do you faint (or feel like you are going to faint)?
• What are you doing when you faint (or feel like you are going to faint)?
• Have you ever lost consciousness?
• Does the fainting (of feeling like you are going to faint) occur suddenly?
• In what position were you when you fainted (or felt like you were going to faint)?
• Have you noticed anything that seem to be associated with the fainting (feeling like you are going to faint), for example, chest pain, irregular heart beat, nausea, confusion, hunger, tingling, or numbness?
• Do you have any black, tarry bowl movements after the fainting episode?
• Do you have heavy periods?

Fatigue

• How long have you felt fatigued?
• Did the fatigue come on suddenly or gradually?
• Do you feel tired all day or only in the morning and/or evening?
• Do you feel more tired at home or at work?
• Is your fatigue relieved by rest?
• When do you feel least tired?

General

• Have you ever had any problems with your heart?
• Have you ever had angina or a heart attack?
• Have you ever had a cardiac catheterization or heart surgery?
• Do you have high blood pressure?
• Have you ever been told you had a heart murmur or had rheumatic fever?
• Have you ever had phlebitis (pain) or swelling in your legs?

Hemoptysis (coughing up blood)

• How long have you been coughing up blood?
• How often do you cough up blood?
• Do you have chest pain when you cough up blood?
• How much blood do you cough up?

Irregular Heart Beat

• Do you have any problems with irregular heart beat or palpitations (when you can feel your heart beating fast or irregular)?
• How long have you had the irregular heart beats?
• When did you first notice the irregular heart beats?
• How long did the irregular heart beats last?
• What did the irregular heart beats feel like?
• Did anything you do stop the irregular heart beats?
• Did the irregular heart beats stop abruptly?
• Could you count your pulse during the episode?
• Can you tap on the table what the rhythm felt like?
• Have you noticed the irregular heart beats during exercise?
• Did you experience any sweating, flushing, or headaches with your irregular heart beats?
• Any you taking any medications, if so, which ones?
• Has anyone ever told you that you had problems with your thyroid gland?
• Do you smoke or use any other recreational or street drugs, if so, how much and how often?
• How much caffeine do you drink a day (coffee, tea, soft drinks)?
• After the irregular heart beats, do you need to urinate?

(18 December 2008)
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