Cardiac medical history taking
We will now describe cardiac medical history taking. As with all medical history taking ..
Listen to your patient, he is telling you the diagnosis”. Dr William Osler (1849-1919)
.. and 90% of the diagnosis is in the medical history. Full stop.
Murmurs are important but not as important as a careful history; and the pulse rate, BP, JVP, and listening to the bases, on examination.
It is important to ask questions about all of the cardiovascular system (CVS), including the peripheral vascular system (e.g. pulses). These questions can be used in a clinical or examination setting.
Pre-introduction observation (before questions)
Before you start, stop, slow down and think. Just for 15 seconds.
Right. Antennae up. Observe the patient and environs around the patient. Why?
Observation is 90% of medicine”
What can you see? What’s their biological age? Walking pace? How are they dressed (and why)? What are they reading (and why)? Are they in pain (from where)? What’s their mood? Are they short of breath or have ankle swelling (fluid overloaded)? Dizzy and maybe falling (low BP? dry?)?
Wash hands. Now you can ask questions. Clock on. Here we go ..
How to take a cardiac medical history
These are ten questions you can ask, and the words to use. They can be asked in ten minutes.
1. Introduction – Start with a diagnostic handshake. “Hello, my name is XX and I’m a student doctor YY. You are Mr/Mrs ZZ and you are AA years old. Is that correct?” You can ask date of birth but that takes longer and you have to do mental arithmetic to calculate the age. The handshake is also a diagnostic tool.
2. PC – “What is the current problem?” Listen very (very) carefully. The diagnosis is often in the patient’s first few words. Write it down. Come back to that at the end.
3. HPC – “Please tell me more about the problem”. Ditto.
Symptoms may be specific to the CVS, e.g. ischaemic sounding chest pain or palpitations; or less specific, e.g. chest pain on inspiration, coughing, moving and sitting forward (pericarditic), which are the same features of pleuritic pain.
Alternatively symptoms may be very non-specific, as there are other (non-cardiac) causes, e.g. fatigue, collapse, shortness of breath (SOB) or ankle swelling.
To save time, ask relevant questions from systems review here. These include questions about cough, haemoptysis (pulmonary oedema is one cause), calf swelling, dizziness, nausea and sweating. You will not have time to do a full systems review.
4. PSH – “What major operations have you had?”. You are especially interested in heart surgery (e.g. CABG and/or valve replacement). An AAA or vascular surgical operation may be relevant too, as it can suggest ischaemic disease (IHD) is some or all of the diagnosis.
5. PMH – “Have you ever had .. diabetes (important in cardiac disease), jaundice, anaemia, CKD, tuberculosis, heart attacks, strokes, high blood pressure (also important), epilepsy, rheumatic fever (very important), or ulcers in your tummy?”
Specific cardiac questions include: “are you known to have chronic heart failure (CHF), or atrial fibrillation (AF)? and “have you had a pacemaker (PPM) or cardiac ablation?”
You need to have finished PMH by 5 mins
6. Drugs/Allergies – “Please show me a list of your current medication? And have you had a major allergic reaction to any medication?”
The medication history is an important part of a cardiac history, especially anti-hypertensive agents, and anti-arrhythmic agents. You need to take it carefully.
Also. All drugs that affect the kidney can affect the heart, e.g. CKD can worsen heart failure (cardiorenal syndrome). Many drugs – e.g. ACE/ARB, SGLT2is, diuretics, NSAIDs, recent chemotherapy, lithium and spironolactone – can cause or worsen CKD and/or hyperkalaemia, and may need to be stopped.
7. SH – “Are you married, how many children have you had, and what is/was your current/last job?”
Occupation is rarely relevant for cardiac disease. But you should still ask about their current or last job.
8. SH – “Have you ever smoked, and have you ever been a regular heavy drinker?”
Smoking is the primary risk factor (with age) for ischaemic heart disease (and therefore for CHF).
9. FH – (depending on age of patient) “Are your parents alive fit and well? OR “Are your parents still with us?” Depending on answer, “what did they die of?” OR “What did your parents die of?” AND “Are there any diseases that run in the family?”
“Has anyone in your family ever had a cardiomyopathy ” (you are looking for HOCM primarily)
“Has anyone in your family had any funny or rare diseases?” (e.g. Friedreich’s ataxia)
You need to have finished SH/FH by 8 mins, to give time for ..
10. ICE – “What are your ideas about what’s going on, and what are your concerns and expectations (of us)?” (2 min). This also gives time for you to think what have you forgotten .. did you ask about medication/allergies and/or smoking/alcohol?
At this point, the patient may give you crucial information like they have IHD (e.g. have had an MI) or a pacemaker.
Summary
We have described cardiac medical history taking. The drug history is important. We hope you have found it useful. Like all history taking, the only way to get good at it, is to practice alot (alot).
Other resource
