11/13/24, 8\:08 PM Guide | Cardiovascular history

Cardiovascular history

Table of contents
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Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
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Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation\:
" O k , s o y o u’ v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u’ d l i k e a d d r e s s i n g. A s t h e r e m a y n o t b e t i m e t o a d d r e s s
t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o d e a l
w i t h t o d a y . I’ l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a gr e e o n w h a t t h e f o c u s o f t o d a y’ s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Patients with cardiovascular pathology can present with a wide variety of symptoms including but not limited to, chest pain,
dyspnoea, palpitations, syncope, oedema and fatigue. The SOCRATES acronym (explained below) is a useful tool that you can
use to explore each of the patient's presenting symptoms.
Key cardiovascular symptoms
Symptoms that are typically associated with cardiovascular disease include\:
Chest pain\: typically central or left-sided (e.g. pericarditis) and may radiate to the left arm and jaw (e.g. acute coronary
syndrome). In some cases, patients having a myocardial infarction may complain of neck pain rather than chest pain.
Dyspnoea\: shortness of breath which may be exertional, related to lying down (orthopnoea) or wake the patient from
sleep (paroxysmal nocturnal dyspnoea).
Palpitations\: a sensation of a fast-beating,
useful to ask the patient to tap out the rhythm to assess its regularity.
Syncope\: rapid onset loss of consciousness (LOC) secondary to reduced cerebral perfusion. The LOC is typically short
in duration with the patient recovering spontaneously. Syncope may be associated with sudden changes in posture
(e.g. postural hypotension), exertion (e.g. aortic stenosis) or occur randomly (e.g. arrhythmia).
Oedema\:
the context of a cardiovascular history, the cause of oedema is most likely to be congestive heart failure or a side e
of medications such as amlodipine.
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Intermittent claudication\: muscle pain, typically in the calf, that develops during mild exertion and resolves upon
resting. Intermittent claudication is caused by inadequate arterial supply secondary to peripheral vascular disease.
Systemic symptoms\: these can include fatigue (e.g. congestive heart failure), fever (e.g. pericarditis, endocarditis),
weight loss (e.g. endocarditis, atrial myxoma) and weight gain (e.g. congestive heart failure).

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient's presenting symptoms in more detail. It is most
commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may
not be relevant to all symptoms.
Site
Ask about the location of the symptom\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Onset
Clarify how and when the symptom developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" W h a t w e r e y o u d o i n g w h e n t h e p a i n s t a r t e d ?"
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e p a i n ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. dull ache, throbbing, sharp)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Radiation
Ask if the symptom moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
" H a v e y o u n o t i c e d t h e c h e s t p a i n s p r e a d i n g t o w a r d s y o u r a r m , b a c k o r n e c k ?"
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?" (e.g. nausea or dyspnoea in angina, fever in pericarditis,
weight gain in heart failure)
Time course
Clarify how the symptom has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?" (e.g. exertion in angina, lying
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. glyceryl trinitrate in angina, leaning forwards in pericarditis)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
You can also ask how far a patient is able to walk (either on the
experience chest pain or signi
Cardiovascular risk factors
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When taking a cardiovascular history it's essential that you identify risk factors for cardiovascular disease as you work
through the patient's history (e.g. past medical history, family history, social history).
Important cardiovascular risk factors include\:
Hypertension
Hyperlipidaemia
Diabetes
Family history of cardiac disease
Smoking

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
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

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l
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Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers, weight change, fatigue
Respiratory\: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
Gastrointestinal\: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
Genitourinary\: oliguria, polyuria
Neurological\: visual changes, motor or sensory disturbances, headache
Musculoskeletal\: chest wall pain, trauma
Dermatological\: rashes, ulcers

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. coronary artery bypass grafts, coronary artery
stents, heart valve replacements, pacemakers)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
Medical conditions relevant to cardiovascular disease include\:
Hypertension
Hyperlipidaemia
Angina
Myocardial infarction
Heart failure
Obesity
Chronic kidney disease
Atrial
Stroke
Peripheral vascular disease
Rheumatic fever
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Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications commonly prescribed to patients with cardiovascular disease include\:
Beta-blockers (e.g. atrial
Calcium channel blockers (e.g. hypertension)
ACE inhibitors (e.g. hypertension, heart failure)
Diuretics (e.g. heart failure)
Mineralocorticoid receptor antagonists (e.g. heart failure)
Statins (e.g. coronary artery disease)
Antiplatelets (e.g. coronary artery disease)
Anticoagulants (e.g. atrial
SGLT-2 inhibitors (e.g. heart failure)
Glyceryl trinitrate spray (e.g. angina)
Some over the counter drugs which may impact the cardiovascular system include\:
NSAIDs (e.g. aspirin, ibuprofen)\: worsen heart failure, increase risk of myocardial infarction in at-risk patients
St John's Wort\: an enzyme inducer that can reduce the e

Family history

Ask the patient if there is any family history of cardiovascular disease\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y h e a r t p r o b l e m s ?"
Clarify at what age the cardiovascular disease developed (disease developing at a younger age is more likely to be associated
with genetic factors)\:
" A t w h a t a g e d i d y o u r f a t h e r s u
" W h e n w a s y o u r m o t h e r
If one of the patient's close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
" I' m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?"
If the patient reports unexplained sudden deaths in young relatives, consider the possibility of cardiac channelopathies (e.g.
Brugada syndrome, long QT syndrome).

Explore the patient's social history to both understand their social context and identify potential cardiovascular risk factors.
General social context
Explore the patient's general social context including\:
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the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Ask if the patient vapes or uses E-cigarettes, even if they are an ex- or non-smoker.
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Recreational drugs may be the underlying cause of a patient's presentation with cardiovascular symptoms\:
Cocaine, ecstasy and amphetamines activate the sympathetic nervous system and thus have similar cardiovascular e
which can include tachycardia (palpitations), blood pressure abnormalities (dizziness, headache) and coronary artery
vasospasm (chest pain).
Opiates including morphine and heroin activate the parasympathetic nervous system leading to bradyarrhythmias and
hypotension (syncope).
Cannabis activates the sympathetic nervous system at low doses (e.g. tachycardia, hypertension) and the parasympathetic
nervous system at higher doses (e,g, bradycardia, hypotension).
Intravenous drug use of any kind predisposes patients to bacterial endocarditis.
Gambling
Ask the patient if they gamble and if they feel this is a problem.
Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent
gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have
substance misuse issues.
1
Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).
Diet
Ask if the patient what their diet looks like on an average day. Take note of unhealthy foods which are known to contribute to
cardiovascular disease (e.g. high salt intake, high saturated fat intake).
Exercise
Ask if the patient regularly exercises (including frequency and exercise type).
Occupation
Ask about the patient's current occupation\:
Assess the patient's level of activity in their occupation (sedentary jobs are associated with increased cardiovascular risk).
If the patient is experiencing episodes of syncope and works with heavy machinery or at heights, it is important to advise
them to take time o
Driving
If the patient drives and has presented with syncope or other concerning cardiovascular symptoms it is important to advise
them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current
medical issues.
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Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
1. References
World Health Organisation. T h e e p i d e m i o l o g y a n d i m p a c t o f g a m b l i n g d i s o r d e r a n d o t h e r ga m b l i n g-r e l a t e d h a r m . 26-28 June 2017. Available from\: [LINK].
Published

Reviewer

Dr Elizabeth Ferguson
General Practitioner
Source\: geekymedics.com
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