OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Chest Pain or Discomfort

  • Is it exertional, positional, pleuritic, tender, or does it occur at rest?
    • Exertional
      • Chronic, stable angina pectoris
      • LVOTO (left ventricular outflow tract obstruction, e.g. AoS, HOCM)
      • Pulmonary HTN
    • Positional
      • Pericarditis
      • Angina decubitus
      • GI: GERD, Pancreatitis
    • Pleuritic
      • Pericarditis
      • Mitral valve prolapse
      • Pneumonia
      • Pulmonary embolism
      • Pneumothorax
      • Pleurodynia/pleurisy
    • Resting
      • Acute coronary syndrome
        • ST elevation myocardial infarction
        • Non-ST elevation myocardial infarction
        • Unstable angina
      • Aortic dissection
      • Mitral valve prolapse
    • Early morning
      • Variant (Prinzmetal) Angina
  • Other (Non-cardiac-rule out life-threatening causes first)
    • GERD
    • Esophageal spasm
    • Peptic ulcer disease
    • Costochondritis
    • Herpes zoster
    • Pancreatitis
  • If of ischemic origin, often described as:
    • "Like an elephant sitting on my chest"
    • "Like a pressure"
    • "Like a burning sensation" (don’t be fooled, burning ≠ GI)
    • "Like a choking in my throat"
    • If previous CAD Hx, is it the same as previously.
  • If of ischemic origin, often brought on by the four E's:
    • Exercise
      • Canadian Cardiovascular Society Classification of Angina
      • Grade 1: No angina with ordinary physical activity
      • Grade 2: Slight limitation of ordinary activity
      • Grade 3: Marked limitation of ordinary physical activity
      • Grade 4: Inability to carry on any physical activity or angina syndrome may be present at rest
    • Emotional stress
    • Exposure to hot or cold
    • Eating a heavy meal
  • Note: Cardiac transplant patients do not feel ischemic pain because of denervation of donor heart
  • Duration
    • Angina usually lasts < 2-10min
    • Myocardial infarction has a variable duration, usually longer than 30min
  • Aggravating/Relieving factors:
      Angina
      • Relieved by rest and nitroglycerin
      • Unstable angina: increase in frequency or severity compared to baseline, chest pain at rest, and any new-onset chest pain
      • Minimal Canadian Cardiovascular Society Classification (CCSC) Class III see above
      Myocardial infarction
      • Unrelieved by rest or nitroglycerin
      • Patient may report nausea/vomiting, diaphoresis, SOB, fatigue and radiation of pain to jaw, left arm, or in bilateral arms
      • see Evidence Based Approach
      Pericarditis
      • Aggravated by deep breathing, rotating chest, or supine position
      • Relieved by sitting up and leaning forward

Dyspnea

  • Cardiac vs. Pulmonary Dyspnea
    • Cardiac
      • Sudden onset (MI, flash pulmonary edema)
      • Associated with CP and/or palpitations
      • Associated with bilateral pedal edema
      • Orthopnea
      • Paroxysmal nocturnal dyspnea
    • Pulmonary
      • Sudden (PE, pneumothorax, anaphylaxis) or chronic (COPD, asthma)
      • Pulmonary sources: associated with unilateral leg swelling, posterior tenderness, tachycardia, immobility, hemoptysis, previous DVT, or malignancy

Fatigue

  • As congestive heart failure (CHF) worsens, fatigue may replace dyspnea as the major complaint

Cough

  • Cough due to cardiac disease is often dry, non-productive, and occurs first when lying flat and nocturnally.

Palpitations

  • Have the patient tap out the beat with his/her hands. Is it a fast flutter? Is it a slow pounding? Is it an occasional missed beat?

Pre-Syncope/ Syncope/ "Dizziness"

  • What type is it?
    • Neurocardiogenic (vasovagal) – from extra PNS output
      • Prolonged standing
      • Situational
      • Shaving
      • Tight collar
      • Head turning
      • Urinating/ coughing/ defecating (Valsalva)
      • Associated with prodrome (nausea/diaphoresis)
    • Orthostatic hypotension – from lack of SNS output
      • Over-medication (beta-blockers, calcium channel blockers, other anti-hypertensives)
      • Dehydration
      • Blood loss
      • Diabetes mellitus
      • Anemia
      • Peripheral neuropathy
      • Older age
    • Arrhythmia related
      • Sudden onset with no prodrome
    • Seizure related
    • Valvular related
      • Previously known pathology
    • CNS Related
      • Stroke
      • Trauma
Additional symptoms
  • Edema/weight gain
  • Intermittent Claudication
  • Nausea/Vomiting
  • Diaphoresis
  • Note: Women/elderly patients present differently when it comes to cardiovascular disease

Past Medical History (PMHx)

  • CAD (Angina or MI)
  • TIA or stroke
  • HTN, diabetes mellitus, dyslipidemia
  • PVD
  • Anxiety
  • Arrhythmias
    • A-fib, WPW, SVT, Pacemaker
  • Valvular Abnormalities
    • Congenital or acquired
  • History of rheumatic fever
  • Major hospitalizations/surgeries
  • Recent dental work, previous pregnancies
  • History of DVT or PE

Family History (FmHx)

  • Cardiovascular disease with age of onset and patient outcomes
    • Family history only positive if first degree relative who is:
      • Male and event occurs before age of 55
      • Female and event occurs before age of 65

  • Genetic and/or congenital abnormalities
    • Marfan syndrome
    • Connective tissue diseases
  • Abdominal Aortic Aneurysm
  • Arrhythmias

Social History (SocHx)

Specifically ask about:

  • Stressors
  • Diet
    • Frequency and use of caffeinated beverages
    • Alcohol
    • Fatty foods
    • GERD producing foods: Citrus fruits, caffeine, chocolate, spicy foods, etc.
  • Occupational exposures
    • Drilling
    • Mining
    • Mould
    • Smoke
    • Sound

Substance Use History (SubHx)

Medications

Gather complete list, including particularly relevant drugs such as:

  • Antiplatelets: ASA, Clopidogrel (Plavix),Ticagrelor, Aggrenox, Prasugrel
  • Anticoagulants: Warfarin, Pradaxa, Rivaroxaban, Apixiban
  • Nitroglycerin spray/patch
  • Beta blockers: Metoprolol, Bisoprolol, Carvedilol
  • Calcium Channel Blockers: Non-dihydropuridines, Dihydropuridines
  • Antiarrhythmics:Propranolol, Amiodarone
  • Statins: Atorvastatin (Lipitor), Rosuvastatin (Crestor), Ezetrol
  • Digoxin
  • Antipsychotics (long QT interval)

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. 3. Andreoli, TE., Benjamin, IJ., Griggs, RC., and Wing, EJ. Cecil Essentials of Medicine, 8th edition. Section III: Cardiovascular disease. Philadelphia. PA. Saunders Elsevier; 2010 : 22-186
  2. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th edition. Head and Neck chapter. Philadelphia. Lippincott Williams & Wilkins; 2007.
  3. McGee S. Evidence based physical diagnosis, 2nd ed. St. Louis, MO : Saunders Elsevier; 2007 : 210.