History Taking of Cardiovascular Problems

Dr.Ira Andaningsih SpJP Cardiovascular Block 2008

Learning Objective
Ask the chief complaint of Cardiovascular disease Ask the detail question about the present symptoms of Cardiovascular disease (angina pectoris, palpitation, dispnea, syncope, fatigue, edema, cyanosis, hemoptysis). Ask about past medical history (medicine, lab. result). Ask about the risk factor of cardiovascular disease. Ask about the occupational and environmental history (smoking, exercise, alcohol). Ask about the family history.

Activities :
1. 3 students will perform doctor-patient communication in a role play 2. The student will start to take the patient medical history by greeting the patient 3. 2 another students will act as a patient and his/her family. 4.The rest students become the observers and will observe, analyze, and fill up the check list. They have to report the observation results and watch the communication process and communication skill.

Method :
Autoanamnesis : Communication with the patient directly.
1.

Alloanamnesis : Communication with the patient's family / friend because the patient couldn't able to do it by him / herself (baby / children, unconscious).
2.

Technique
1. 2. 3. 4. Ask the patient's identity Ask the chief complaint. Ask the associate complaint. Ask the present medical history 5. Ask the past medical history 6. Ask the family medical history 7. Behavior

Cardinal symptoms of heart disease

1. 2. 3. 4. 5. 6. 7.

8.
9.

Chest Pain Dyspnea Cough Hemoptysis Palpitation Syncope/collapse Cyanosis Edema Others.

Pain
1. Location 2. Radiation 3. Quality 4. How long it has been present 5. How long each episode lasts 6. The factors that produce and relieve 7. Describe pain (pressing, dull ?)

Pain
1.

Pain due to myocardial ischemia, is called angina pectoris 2. Pain due to dissecting aneurysm of the aorta. 3. Pain due to Acute Pericarditis 4. Pain due to non cardiac 5. Pain in the extremities.

Characteristic of chest pain

Angina
Duration Precipitated by Relieve by Intensity Minutes Effort,emotion, eating, cold Rest, nitroglycerine Mild to severe

Not angina
Seconds,hours, days Respiration, posture,motion Nonspecific Excruciating

Characteristic of chest pain

Location

Angina Retrosternal, diffuse

Radiation

Description
Intensity

Left arm, jaw, back Aching,dull,pres Sharp,shooting, sing,squeezing cutting Mild to severe Excruciating

Not angina Left intramammary. localized Right arm

Common cause of chest pain

Cardiac Vascular Pulmonary CAD,AVdisease, PH, MVP,Pericarditis Dissection of the aorta Pulm emboli,Pneumonia, Pleuritis,Pneumothorax

Musculoskeletal

Costochondritis,arthritis, Muscular spasm,bone ca

Common cause of chest pain

Neural Herpes zoster

Gastro intestinal

Emotional

Ulcer,Hiatal hernia, pancreatitis,cholecystitis, bowel disease Anxiety, depression

Dyspnea
1.Dyspnea

on effort (DOE) 2.Orthopnea 3.Paroxysmal Nocturnal Dyspnea(PND) 4.Acute Pulmonary Edema

Common cause of dyspnea

Cardiac
Pulmonary

LV failure,MS
Asthma,Obstructive/restri ctive lung disease,Pulm embolism,PH Anxiety

Emotional

High altitude exposure

Anemia

Decreased O2 pressure
Decreased O2 carrying capasity

Palpitation
Is

awareness of the heart beat. The patient may use some other term and report a pounding, stopping , jumping , or racing in the chest.

Common cause of palpitation

1.Extrasystole 2.Tachyarrhythmia 3.Bradyarrhythmia

4.Drugs
5.Smoking 6.Caffeine 7.Thyrotoxicosis

Cough
A

dry, non productive cough( pulmonary congestion associated with heart failure) It may develop by effort but may also occurs at rest The cough which accompanies pulmonary edema is often associated with frothy, pink sputum.

Edema
History of edema of the leg in the evening is characteristic of heart failure or bilateral chronic venous insufficiency. Inability to fit the feet into shoes is a common early complain. In most patient any visible edema of both lower extremities is preceded by a weight gain of at least 7 to 10 lbs. Cardiac edema is generally symmetrical.

Edema
Edema in abdomen and legs is observed in heart failure and hepatic cirrhosis. Edema may be generalized ( anasarca ) in the nephrotic syndrome, severe heart failure, and hepatic cirrhosis. Edema around the eyes and face is characteristic of the nephritic syndrome, acute glomerulonephritis, angioneurotic edema, hypoproteinemia, and myxedema.

Edema
Edema limited to the face, neck, and upper arms may be associated with obstruction of the superior vena cava (carcinoma of the lung, lymphoma, aneurysm of the aortic arch) Edema restricted to one extremity is usually due to venous thrombosis or lymphatic blockage of that extremity. History of dyspnea associated with edema is most frequently due to heart failure.

Syncope
Cardiac

syncope is usually of rapid onset without aura, and is usually not associated with convulsive movement. Syncope in aortic stenosis is precipitated by effort Syncope associated with chest pain maybe secondary to massive myocardial infarction or infarction associated with arrhythmia

Syncope
A

family history of syncope/ near syncope in patient with hypertrophic obstructive cardiomyopathy or ventricular tachyarrhythmia associated with long QT. Syncope associated with progressive intensification of cyanosis in an infant or child with cyanotic congenital heart diseases.

Common cause of syncope

Cardiac Metabolic Neurologic Arrhythmia,LV output obstruction Hypoglycemia,hypoxia, hyperventilation Epilepsy, CVD

Psychiatric

Hysteria

Common cause of syncope

Orthostatic hypotension Volume depletion,anti depression,antihypertensi on Vasodepression
Visceral reflex Chronic lung disease Vasopressor response to carotid sinus sensitivity

Vasovagal
Micturition Cough Carotid sinus

Cyanosis
Discoloration of the skin and mucous membrane resulting from an increased quantity of reduced hemoglobin or of abnormal hemoglobin pigments in the blood perfusing these area. There are 2 principal forms of cyanosis: 1. central cyanosis 2. peripheral cyanosis Cyanosis generally occurs in patient with congenital heart disease.

Hemoptysis
1. Escape of red cells into the alveoli from congested vessels in the lungs ( acute pulmonary edema ). 2. Rupture of dilated endobronchial vessels that form collateral channels between the pulmonary and bronchial venous systems ( Mitral stenosis ). 3. Necrosis and hemorrhage into the alveoli ( pulmonary infarction ). 4. Ulceration of the bronchial mucosa ( tbc)

Hemoptysis
5. Vascular invasion ( carcinoma of the lung ). 6. Necrosis of the mucosa with rupture of pulmonary bronchial venous connection ( bronchiectasis ). 7. A history of hemoptysis that associated with shortness of breath suggests mitral stenosis. 8. Hemoptysis associated with congenital heart disease and cyanosis suggests Eisenmenger syndrome.