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:
      • 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
      • Aggravated by deep breathing, rotating chest, or supine position
      • Relieved by sitting up and leaning forward


  • 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


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


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


  • 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)


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)


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


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.


  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.