Cardiovascular history taking is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough cardiovascular history.
Opening the consultation
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Ensure the patient is comfortable
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
History of presenting complaint
Onset – When did the symptom start? / Was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is chest pain, how bad is it on a scale of 1 to 10?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. GTN spray
Associated features –are there other symptoms that appear associated e.g. fever / malaise
Previous episodes – has the patient experienced this symptom previously?
Key cardiovascular symptoms:
- Chest pain – SOCRATES
- Dyspnoea – exertional / orthopnea / paroxysmal nocturnal dyspnoea
- Palpitations – ask patient to tap out the rhythm
- Syncope / dizziness – postural / exertional / random
- Oedema – peripheral oedema (e.g. lower limbs) / sacral oedema
- Intermittent claudication – e.g. leg pain worsened on exertion / improved at rest
- Systemic symptoms – fatigue / fever / weight loss / weight gain
If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course / Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes)
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
- Site – where is the pain
- Onset – when did it start? / sudden vs gradual?
- Character – sharp / dull ache / burning
- Radiation – does the pain move anywhere else?
- Associations – other symptoms associated with the pain
- Time course – worsening / improving / fluctuating / time of day dependent
- Exacerbating / Relieving factors – anything make the pain worse or better?
- Severity – on a scale of 0-10, how severe is the pain?
CARDIOVASCULAR RISK FACTORS:
- Family history of cardiac disease
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
- What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Past medical history
- Myocardial infarction – bypass grafts / stents
- Atrial fibrillation
- Peripheral vascular disease
- Rheumatic fever
Other medical conditions – e.g. hyperthyroidism
Surgical history – bypass graft / stents / valve replacements
Acute hospital admissions? – when and why?
- Beta blockers
- Calcium channel blockers
- ACE inhibitors
- Glyceryl trinitrate spray (GTN spray)
Other regular medications
Contraceptive pill – increased risk of thromboembolic disease
Over the counter drugs – NSAIDS / Aspirin
Herbal remedies – e.g. St John’s Wort – enzyme inducer (can affect Warfarin levels)
ALLERGIES – ensure to document these clearly
Cardiovascular disease at a young age – myocardial infarction / hypertension / thrombophilia
Are parents still in good health? – if deceased sensitively determine age and cause of death
Any unexplained deaths in young relatives? – long QT syndrome / channelopathies
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type / volume / strength of alcohol
Recreational drug use – e.g. Cocaine – coronary artery vasospasm
Diet – Overweight? Fatty foods? Salt intake? – cardiovascular risk factors
Exercise – baseline level of patient’s day to day activity
- House/bungalow? – adaptations / stairs
- Who lives with the patient? – is the patient supported at home?
- Any carer input? – what level of care do they receive?
Activities of daily living:
- Is the patient independent and able to fully care for themselves?
- Can they manage self hygiene / housework / food shopping?
Occupation – sedentary jobs – ↑ cardiovascular risk – e.g. lorry driver
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
Summarise the history