Tag Archives: Cardiovascular history

APPROACH TO SYNCOPE

APPROACH TO SYNCOPE
History taking in cardiology cont.
Syncope has been defined by the European society of cardiology as “A transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous recovery.”
Syncope is a common problem, it causes significant agony and apprehension and may result in serious injury to the patient. Analysing and making an etiologic diagnosis of syncope is a difficult problem and even after investigations a significant number of patients still remain unexplained.
A detailed history is of paramount importance in the evaluation of syncope. Because all evaluation is usually retrospective. We will discuss in this article an approach to syncope and how to make a probable diagnosis from history.

STEPS IN THE EVALUATION OF SYNCOPE:
Patients present with the complain of loss of consciousness. From here we have to proceed in a systematic fashion to make a diagnosis. We will approach syncope under two headings
1. Taking the history of the episode
2. Analysing the history to reach at a diagnosis

RECORDING THE HISTORY OF SYNCOPE:

Below is a sample questionnaire for recording the history
WHAT WERE THE CIRCUMSTANCES JUST PRIOR TO THE ATTACK?

• The physical position of the patient is important. Inquire whether the patient was supine, sitting or standing.

• Activity related to syncope episode (rest. change in posture, during or after exercise, during or immediately after urination, defecation cough, or swallowing)
• Predisposing factors (e.g. crowded or warm places, prolonged standing. post-prandial period) and of precipitating events (e.g. fear, intense pain, neck movements)

HOW THE ATTACK STARTED ?
• Nausea, vomiting, abdominal discomfort, feeling of cold, sweating, aura, pain in neck or shoulders, blurred vision, dizziness
• Palpitations

QUESTIONS ABOUT THE ATTACK (EYEWITNESS)
• Way of falling (slumping or kneeling over), skin color (pallor, cyanosis, flushing), duration of loss of consciousness, breathing pattern (snoring) movements (tonic, clonic, tonic-clonic, minimal myoclonus or automatism), duration of movements, onset of movement in relation to fall, tongue biting
HOW THE ATTACK ENDED?
• Nausea, vomiting, sweating, feeling of cold, confusion, muscle aches, skin color, injury, chest pain, palpitations, urinary or fecal incontinence
BACKGROUND HISTORY OF THE PATIENT
• Family history of sudden death, congenital arrhythmogenic heart disease or fainting
• Previous cardiac disease
• Neurological history (Parkinsonism, epilepsy, narcolepsy)
• Metabolic disorders (diabetes, etc.)
• Medication (antihypertensive, antianginal, antidepressant agent, antiarrhythmic, diuretics, and QT-prolonging agents) or other drugs including alcohol
• In the case of recurrent syncope, information on recurrences such as the time from the first synopal episode and on the number of spells

ANALYSIS OF HISTORY
Once the history is recorded, the next step is to differentiate syncope from other causes of transient loss of consciousness.
Causes of transient loss of consciousness (T-LOC)

1. Syncope – we will discuss
2. Neurologic or cerebrovascular disease – e.g. seizure, posterior circulation TIA
3. Metabolic syndromes and coma – e.g. hypoglycaemia, drug or alcohol intoxication, hypoxia, hypocapnea
4. Psychogenic syncope- anxiety disorders, panic disorders, somatization disorders
DIFFERENTIATING SYNCOPE FROM OTHER CAUSES OF T-LOC
Following questions help in differentiating syncope from other causes of T-LOC
(1) Did the patient experience a complete loss of consciousness?
(2) Was the loss of consciousness transient with rapid onset and short duration?
(3) Did the patient recover spontaneously, completely, and without sequelae?
(4) Did the patient lose postural tone?
If the answer to one or more of these questions is negative, other nonsyncopal causes (as listed above) of transient loss of consciousness should be evaluated.
ESTABLISHING THE CAUSE OF SYNCOPE
Features of some of the common causes of syncope

Neutrally mediated syncope Arrhythmia Seizure Psychogenic
EpidemiologyAnd clinical setting Female>malesYounger age (<55)Frequent episodes(>2)

Prolonged standing, extreme emotions, hot humid surrounding

 

Structural heart diseaseMales>femalesOlder age (>55 years)

Lesser episodes(<3)

In supine position or during exertion

Family history of sudden cardiac death

Younger age (<45yrs)Any clinical situation Females>malesOccurs in others presenceYoung age (<40 yrs)

Many episodes (many episodes in a day)

No definite trigger

 

Premonitory symptoms Longer duration(>5s)PalpitationsBlurred vision

Nausea

Warmth

Diaphoresis

Light-headedness

Shorter duration(<6s)Palpitation less common Sudden onsetBrief aura (déjà vu, olfactory, gustatory, visual Usually absent
During the episode Pallor & diaphoresisDilated pupilHypotension

Bradycardia

Urine and fecal incontinence

Brief clonic movements may occur

 

Cyanosed not paleIncontinenceClonic movements may occur Cyanosed, no pallorTongue bitingFrothing at mouth

Prolonged syncope(>5 mins)

Hypertension

Tachycardia

Horizontal eye deviations

Tonic-clonic movements

Normal colourNormal pulse and BPProlonged duration

No incontinence

Eyes closed

Residual symptoms CommonFatigueOriented Residual symptoms uncommon (unless prolonged unconsciousness) CommonMuscle achesDisorientation

Fatigue

Headache

Slow recovery

uncommon

 

Salient features of syncope due to less common causes

Cause of syncope Salient features
  1. Vascular steal syndromes (subclavian steal syndrome)

 

 

Syncope in association with symptoms of brain stem ischemia (i.e.,diplopia,tinnitus,focal weakness or sensory loss, vertigo, dysarthria.
  1. Migraine associated syncope
Throbbing unilateral headache, scintillating scotomata, nausea, vomiting, photophobia, phonophobia
  1. Orthostatic hypotension
History of orthostatic symptoms and syncope, features of autonomic failure and other neurological symptoms (e.g.,parkinsonism, disturbances of bowel, bladder , thermoregulatory and sexual function, ataxia)-volume depletion-drug and alcohol induced
  1. Carotid sinus hypersensitivity
Common in elderly, relationship to specific neck positions (neck collar, shaving etc.), carotid sinus massage reproduces symptoms or bradycardia
  1. Situational syncope
Related to specific situations ( cough, defecation, laugh, swallow, after food, sneeze, micturition etc.)
  1. Glossopharyngeal syncope
Associated with glossopharyngeal neuralgia

 

These tables provide enough information to help in diagnosis. Clinical history and physical examination has around 25% sensitivity for etiologic diagnosis of syncope. Most of these patients need further evaluation.

Special note for students about to appear in exams:
Remember the structural heart diseases which result in syncope. Important ones
1. LVOTO- aortic stenosis, HCM, coarctation of aorta
2. RVOTO – pulmonary stenosis
3. Pulmonary hypertension
4. Atrial myxoma
These conditions will have a lot of other cardiac symptoms which will help in making a clinical diagnosis. You will have to remember the natural history of important structural heart diseases and exam cases.

This article is part of the series about history taking in cardiology and is intended primarily for medical students. Physicians and practitioners are referred to ESC guideline on evaluation and management of syncope (http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-syncope-ft.pdf).

Keywords : history taking in cardiology, medical students, syncope, symptoms of heart disease, analysis of symptoms

APPROACH TO PALPITATION

APPROACH TO PALPITATION

History taking in cardiology contd…

Palpitation is a common symptom in cardiac patients as well as in patients with a variety of other diseases, sometimes even without diseases. History taking represents a major part of evaluation of patients with palpitation as most patients by the time they visit a physician have no palpitation and the diagnosis has to be made retrospectively.

Before embarking on the understanding of palpitation we should know what palpitation is. As defined by EHRA (European heart rhythm association) “Palpitations are a symptom defined as awareness of the heartbeat and are described by patients as a disagreeable sensation of pulsation or movement in the chest and/or adjacent areas.”

Even though palpitation is a very common symptom it is a difficult problem to evaluate and to make a definitive diagnosis.

Below is given a list of the possible etiologies of palpitation. Take a careful look into the list  so that you understand what we are looking for while taking history of palpitation.

Etiologies of palpitation:

  1. Cardiac arrhythmias

Supraventricular/ventricular extrasystoles

Supraventricular/ventricular tachycardias

Bradyarrhythmias: severe sinus bradycardia, sinus pauses, second and

third-degree atrioventricular block

Anomalies in the functioning and/or programming of pacemakers and ICDs

  1. Structural heart diseases

Mitral valve prolapse

Severe mitral regurgitation

Severe aortic regurgitation

Congenital heart diseases with significant shunt

Cardiomegaly and/or heart failure of various aetiologies

Hypertrophic cardiomyopathy

Mechanical prosthetic valves

  1. Psychosomatic disorders

Anxiety, panic attacks

Depression, somatization disorders

  1. Systemic causes

Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever,

anaemia, pregnancy, hypovolaemia, orthostatic hypotension,

postural orthostatic tachycardia syndrome, pheochromocytoma,

arteriovenous fistula

  1. Effects of medical and recreational drugs

Sympathicomimetic agents in pump inhalers, vasodilators,

anticholinergics, hydralazine

Recent withdrawal of b-blockers

Alcohol, cocaine, heroin, amphetamines, caffeine, nicotine, cannabis,

synthetic drugs

Weight reductions drugs

Now lets go to the history taking proper. Here we will have our standard step-wise approach to history taking and analysis (as mentioned in approach to chest pain)

Step 1: describe the symptom in detail

Step2: localize the symptom to an anatomical system

Step 3: localize the palpitation to an organ/mechanism

Step 4: etiology of palpitation

As described in history taking in cardiology , always begin by noting down the premorbid functional status of the patient. Any change in functional status should be noted.

Step 1.Recording the history of palpitation:

Given here is a scheme of question to ask while taking history of palpitation

  1. Circumstances prior to the beginning of palpitations

Activity (rest, sleeping, during sport or normal exercise, change in

posture, after exercise)

Position (supine or standing)

Predisposing factors (emotional stress, exercise, squatting or

bending)

  1. Onset of palpitations

Abrupt or slowly arising

Preceded by other symptoms (chest pain, dyspnoea, vertigo, fatigue,

etc.)

  1. Episode of palpitations

Type of palpitations (regular or not, rapid or not, permanent or not)

Associated symptoms (chest pain, syncope or near syncope,

sweating, pulmonary oedema, anxiety, nausea, vomiting, etc.)

  1. End of the episode

Abrupt or slowly decreasing, end or perpetuation of accompanying

symptoms, duration, urination

Spontaneously or with vagal manoeuvres or drug administration

  1. Background

Age at the first episode, number of previous episodes, frequency

during the last year or month

Previous cardiac disease

Previous psychosomatic disorders

Previous systemic diseases

Previous thyroid dysfunction

Family history of cardiac disease, tachycardia or sudden cardiac

death

Medications at the time of palpitations

Drug abuse (alcohol and/or others)

Electrolytes imbalance

Step 2:

Once the history of palpitation has been recorded, next step is to localize whether it is cardiac or noncardiac in origin (please refer to the Etiology list for cardiac and noncardiac causes). It may be less reliable to differentiate a cardiac from noncardiac cause of palpitation based on history only. For that associated symptoms really help. Someone who has other symptoms of cardiac disease has more likelihood of having cardiac cause of palpitation.

Step 3:

Among cardiac cause of palpitation our aim is to differentiate arrhythmic from nonarrhythmic causes.

Features which suggest arrhythmic palpitations are

Structural heart disease

Primary electrical heart disease

Abnormal ECG

Family history of sudden death

Advanced age

Tachycardiac palpitations

Palpitations associated with haemodynamic impairment

Below are listed description of some common types of palpitation.

Type ofpalpitation  Subjectivedescription  Heartbeat Onset andtermination  Triggersituations  Possible associated symptoms
Extrasystolic ‘Skipping/missing a beat’, ‘sinking of the heart’ Irregular, interspersed withperiods of normal heartbeat  Sudden Rest
Tachycardiac ‘Beatingwings’ in the chest Regular or irregular, markedly accelerated Sudden Physical effort, cooling down Syncope,dyspnoea,fatigue,chestpain
Anxiety-related Anxiety, agitation Regular,slightly accelerated Gradual Stress,Anxiety attacks

 

Tingling in the hands and face, lump in the throat,atypical chest pain,sighing dyspnoea 
Pulsation Heart pounding Regular,normal frequency Gradual Physicaleffort Asthenia

 

Some features also help to differentiate the different types of arrhythmic palpitations:

Type of arrhythmia Heartbeat Trigger situation Associated symptoms Vagal manoeuvres
AVRT, AVNRT Sudden onset regular with periods of elevated heart rate Physical effort, changes in posture Polyuria, frog sign Sudden interruption
Atrial fibrillation Irregular with variable heart rate Physical effort, cooling down,post meal, alcohol intake Polyuria Transitory reduction in heart rate
Atrial tachycardia and atrial flutter Regular (irregular if A-V conduction is variable) with elevated heart rate Transitory reduction in heart rate
Ventricular tachycardia Regular with elevated heart rate Physical effort Signs/symptoms of hemodynamic impairment No effect

 

These tables will help to delineate the cardiac cause of palpitation.

 

Step 4:

This the final step where all the above discussion culminates in a list of differential diagnosis. The differential diagnosis will look something like this

  1. Arrhythmic palpitation
  2. Structural heart disease e.g.
    1. Valvular regurgitation
    2. Congenital or acquired shunt lesions
  3. Heart failure    etc..

 

In the exams it is a bit difficult to make  differential diagnoses based on palpitation only. There evaluate other cardiac symptoms very carefully. Once all the cardiac symptoms have been analysed then forming differential diagnoses is a bit easy. Yes one more thing read the natural history of cardiac diseases. I will post articles on natural history of cardiac diseases once this discussion on history taking is over.

This outlines the approach to palpitation. I hope it fulfils your purpose. All these articles are intended for medical students and exam goings. For professional there are a few references listed below for further reading.

Further readings:

  1. Weber BE, Kapoor WH. Evaluations and outcomes of patients with palpitations.

Am J Med 1996;100:138–48.

  1. Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient

with palpitations have a cardiac arrhythmia? JAMA 2009;302:2135–43.

  1. Hoefman E, Boer KR, van Weert HCPM, Reitsma JN, Koster RW, Bindels PJE.

Predictive value of history taking and physical examination in diagnosing arrhythmias

in general practice. Fam Pract 2007;24:636–41.

  1. Managing patients with palpitation. Europace (2011) 13, 920–934

Approach to chest pain

History taking in cardiology cont..

Chest pain is a common symptom of a variety of diseases. Developing a clear and thorough approach to chest pain is immensely important for your day to day practice and also for students for their assessments and exams. The spectrum of diseases producing chest pain range from innocuous conditions like muscle aches to life threatening myocardial infarction and aortic dissection.

Developing an approach to chest pain:

I will discuss in detail the approach which will be applicable for case presentation in exams and also for day to day practice.

The approach to chest pain can be divided into four steps

Step-1: this should include a thorough description of the symptom. Characterize the pain in the best possible detail

Step-2: localization of the pain to the different anatomic systems in the chest like – respiratory system, cardiovascular system, musculoskeletal system, gastrointestinal tract, hepato-pancreato-biliary system, neurological system.

Step-3: since we are mainly concerned with the cardiovascular system, the next step is localization of the chest pain to different cardiac structures – pericardium, coronary arteries, myocardium, endocardial structures and aorta.

Step-4: And finally etiology of chest pain.

A thorough understanding of each step is of paramount importance. At the end of history you should be able to form a list of etiologic differential diagnoses ranked according to priority.

Does this sound too much? Its not actually as you will discover as you read further.

Step-1: describing the chest pain

Describe the chest pain in the following headings

  1. Quality of pain – the common terms used to describe different types of chest pain are deep, boring, chest discomfort, tightness, heaviness, uneasiness, pricking, choking, sharp, shooting, ripping pain etc
  2. Location of pain- try to elicit the exact location by asking the patient to point to point to the site of maximum pain
  3. Radiation of pain
  4. Onset of pain- acute onset or insidious onset
  5. Tempo of progression
  6. Duration of symptoms
  7. Aggravating factors
  8. Relieving factors
  9. Positional variation in pain
  10. Any associated symptoms
    1. Other cardiac symptoms – shortness of breath, palpitation, fatigue, syncope, dizziness, cyanosis
    2. Respiratory symptoms- cough, expectoration, wheezing, hemoptysis, shortness of breath etc
    3. Gastrointestinal symptoms- nausea, vomiting, relation to food, dysphagia, odynophagia,
    4. Any neurological symptoms
    5. Any pain, redness or swelling at site of pain

Once this characterization part is over move to step-2

Step-2: Localization of pain to different organ systems:

The key to localization of the symptom to a particular system is the above characterization of pain. Below is a table of the salient features of each system.

SYSTEM SYNDROME CLINICAL DESCRIPTION KEY DISTINGUISHING FEATURES
Cardiac Angina Retrosternal chest pressure, burning, or heaviness; radiating occasionally to neck, jaw, epigastrium, shoulders, left arm Precipitated by exercise, cold weather, or emotional stress; duration 2-10 min, relieved by rest or nitrates
Rest or unstable angina Same as angina, but may be more severe Typically <20 min; lower tolerance for exertion; crescendo pattern
Acute myocardial infarction Same as angina, but may be more severe Sudden onset, usually lasting ≥30 min; often associated with shortness of breath, weakness, nausea, vomiting
Pericarditis Sharp, pleuritic pain aggravated by changes in position; highly variable duration Pericardial friction rub
Vascular Aortic dissection Excruciating, ripping pain of sudden onset in anterior of chest, often radiating to back Marked severity of unrelenting pain; usually occurs in setting of hypertension or underlying connective tissue disorder such as Marfan syndrome
Pulmonary embolism Sudden onset of dyspnea and pain, usually pleuritic with pulmonary infarction Dyspnea, tachypnea, tachycardia, signs of right heart failure
Pulmonary hypertension Substernal chest pressure, exacerbated by exertion Pain associated with dyspnea and signs of pulmonary hypertension
Pulmonary Pleuritis and/or pneumonia Pleuritic pain, usually brief, over involved area Pain pleuritic and lateral to midline, associated with dyspnea
Tracheobronchitis Burning discomfort in midline Midline location, associated with coughing
Spontaneous pneumothorax Sudden onset of unilateral pleuritic pain, with dyspnea Abrupt onset of dyspnea and pain
Gastrointestinal Esophageal reflux Burning substernal and epigastric discomfort, 10-60 min in duration Aggravated by large meal and postprandial recumbency; relieved by antacid
Peptic ulcer Prolonged epigastric or substernal burning Relieved by antacid or food
Gallbladder disease Prolonged epigastric or right upper quadrant pain Unprovoked or following meal
Pancreatitis Prolonged, intense epigastric and substernal pain Risk factors including alcohol, hypertriglyceridemia, medications
Musculoskeletal Costochondritis Sudden onset of intense fleeting pain May be reproduced by pressure over affected joint; occasionally, swelling and inflammation over costochondral joint
Cervical disc disease Sudden onset of fleeting pain May be reproduced with movement of neck
Trauma or strain Constant pain Reproduced by palpation or movement of chest wall or arms
Infectious Herpes zoster Prolonged burning pain in dermatomal distribution Vesicular rash, dermatomal distribution
Psychological Panic disorder Chest tightness or aching, often accompanied by dyspnea and lasting 30 minutes or more, unrelated to exertion or movement Patient may have other evidence of emotional disorder

 

This table provides a lot of information. Once you go through the table a list of differential diagnoses can be made and appropriate investigations ordered.

The next discussion is for case presentation in exams

Step-3: the above table also helps in localizing the cardiovascular structures causing the pain.

Step-4: Etiology of cardiovascular cause of chest pain:

Finally you have to think of the Etiology of the cardiac chest pain. Now we will examine the common etiologies of chest pain and try to differentiate them clinically.

  1. Coronary artery disease: there will be history of angina as described in the table
  2. Left ventricular outflow tract obstruction (LVOTO): the symptoms of LVOTO are remembered by the letters – ASD- Angina, Syncope and Dyspnea. RVOTO also has similar symptoms. They may have additional features of right heart failure like- peripheral edema, ascites, right upper quadrant pain, neck pulsations, cyanosis etc
  3. Mitral stenosis and less commonly mitral regurgitation can have chest pain. But the predominate symptoms in case of
    1. Mitral stenosis: dyspnea
    2. Mitral regurgitation: fatigue and palpitation
  4. Pulmonary arterial hypertension: can have angina. The predominant symptoms will be dyspnea, fatigue. Associated symptoms can be palpitation, syncope.

This will cover some of the common cardiac causes of chest pain for exam case presentation.

Conclusion: Chest pain is a common symptom with a wide spectrum of presentation. Attention to the details of history will help to narrow down the possible conditions giving rise to the chest pain.

Your comments, suggestions and corrections are most welcome and will greatly help me to improve my articles.

Thank you

Dr. Anupam Jena
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Approach to Dyspnea

History taking in Cardiology Contd….

Continuing our discussion on history taking in cardiology today we will form an approach to dyspnoea.

What is Dyspnea?

A consensus statement of the American Thoracic Society defined dyspnea in the following way1:

“Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses.”

The American Thoracic Society (ATS) statement on the mechanisms, assessment, and management of dyspnea, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.

It is one of the most common presentations of a variety of disorders.

What are we looking for when evaluating dyspnea?

In the approach to any symptom we should have a clear understanding of what we are looking for. Among patients who present with undue dyspnoea we are looking for one of the following major conditions:

  1. Respiratory system disease
    1. Asthma
    2. COPD
    3. Interstitial lung disease
    4. Pulmonary hypertension
  2. Cardiac disease
    1. Valvular heart disease
    2. Myocardial dysfunction either systolic or diastolic
    3. Pulmonary hypertension
    4. Pericardial diseases – though they present with symptoms of biventricular dysfunction or predominant right sided heart failure.
  3. Obesity
  4. Anaemia
  5. Deconditioning

Though this list is not complete but for all practical purposes these are the major differential diagnosis.

How to take history of dyspnoea?

General approach to record cardiac history:

In the description of any cardiac symptom you should proceed in a particular order. First describe the baseline (premorbid) functional status of the patient e.g. something like – the patient was able to walk for 5 kms, play golf, do jogging etc. without any symptoms.

Once the baseline functional status is clearly described go for symptoms. Any symptom should be described as ODP i.e. O= onset, D= duration, P= progression.

Describing the history:

  1. Onset of symptoms
  2. Duration of symptoms
  3. Progression (in terms of NYHA class and time to progression). In cardiovascular history always try to quantify symptoms in terms of NYHA class. Because it is the most widely used and validated.
  4. Describe the dyspnea in patient’s language. Try to ascertain that the patient actually has dyspnea. Sometimes the patient may be having predominant fatigue. Some of the common patient expressions of  dyspnea are like-
    • My breathing is shallow.
    • I feel an urge to breathe more.
    • My chest is constricted.
    • My breathing requires effort.
    • I feel a hunger for more air.
    • I feel out of breath.
    • I cannot get enough air.
    • My breath does not go in all the way.
    • My chest feels tight.
    • My breathing requires work.
    • I feel that I am smothering/suffocating.
    • I feel that I cannot get a deep breath.
    • I feel that I am breathing more.
    • My breath does not go out all the way.
    • My breathing is heavy.
    • Other descriptions

The language of dyspnoea can give a clue to the diagnosis e.g.

    1. Chest tightness or constriction is described in  Bronchoconstriction, interstitial oedema (e.g. Asthma, Myocardial ischemia)
    2. Increased work or effort of breathing is the description in – Airways obstruction, neuromuscular disease, reduced chest wall or pulmonary compliance (COPD, moderate to severe asthma, myopathy, pulmonary fibrosis)
    3. Air hunger, need to breathe, urge to breathe is seen in – increased drive to breathe (HF, pulmonary embolism, moderate to severe asthma or COPD)
    4. Rapid, shallow breathing- reduced chest wall or pulmonary compliance       (Interstitial fibrosis)
    5. Suffocating, smothering- Alveolar oedema (Pulmonary oedema)
    6. Heavy breathing, breathing more- Inadequate oxygen delivery to the muscles- Deconditioning

So carefully listen to the language patients use to describe the symptoms.

5. Variation in dyspnea – positional, diurnal or seasonal variation
6. Associated cough. If cough is there – dry or productive
7. Any history of wheezing
8. Haemoptysis
9. Orthopnoea or PND,History of PND is suggestive of cardiac disease. So always carefully ask for PND
10. Finally mention the present functional status of the patient.
Go to the next symptom like chest pain, palpitation , fatigue etc……only after you finish describing dyspnea

Once you are finished with describing the symptom of dyspnoea, formulate a short summary of the symptom. I will give an example of a summary – “patient had dyspnea which was insidious in onset and progressed from NYHA II to III/IV in …..Years, it is associated with h/o orthopnoea/PND, presently he is NYHA III.”

I hope this discussion is useful to you. Any suggestion, comments or correction is most welcome.

Dr. Anupam Jena
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Reference:

1.         Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine 2012;185:435-52.

 

History taking in Cardiology

History taking in any branch of medicine is the single most important exercise. Most clinical books open with the idea of history taking. In the initial part of medical training students sometimes fail to understand the importance of history taking. But as we go higher in our training we understand the importance of history gradually.

Why a good history is important?

A good history gives the diagnosis, or a list of differential diagnosis in most of the cases. Then you can channelize your investigations in that direction. Another practical need is for facing your clinical assessments and exams. The more you learn of a subject the more you understand about the history. History taking is a difficult job for the beginner. The skill improves with your knowledge in a field of medicine. These posts on “history taking in cardiology” will be an honest attempt by me to discuss the beauty and depth of history taking in cardiology.

How to take history in cardiology?

It is always safer to follow the standard format of history taking.

Patient particulars:

  1. Name
  2. Age
  3. Sex
  4. Address
  5. Educational status of the patient
  6. Occupation
  7. History given by self or parents/relatives
  8. If history given by relatives what do you think of the reliability of information given

When presenting your case in exams make this part of presentation sound like well-articulated sentences, e.g. the patient mr./mrs x.. ,is  a 55… years old male/female. He/she is a resident of y.. he is educated upto … and he/she works as ….history has been given by self/relative.

Make your presentation in a calm and composed manner, don’t sound haphazard and disorganized.

Presenting Complains:

Write the presenting complains in the proper chronological order. All of you might be aware of the chronological order in which symptoms are written. Usually the longest duration symptoms are mentioned first, followed by the second and so on.

Then comes history of present illness (HOPI)

In HOPI you should try to be systematic and proceeding in a well-directed manner. Now is the time to elaborate your presenting complains. It’s like what you want to keep as your diagnosis and differential diagnosis you talk more about them.

Those points we will discuss subsequently.

Basically history of present illness is analysis of symptoms.

What are symptoms of cardiovascular disease?

The presenting symptoms of cardiovascular disorders are

  1. Dyspnoea
  2. Chest pain
  3. Palpitation
  4. Fatigue
  5. Presyncope/Syncope/dizziness
  6. Pedal edema
  7. Neck pulsations
  8. Cyanosis
  9. Murmur
  10. Chest bulging, stunted growth, cyanotic spell – in paediatric cases

We will discuss about these symptoms one by one and how to analyse them

Past history:

Past history should include information about relevant diseases and conditions like diabetes mellitus, hypertension, bronchial asthma, tuberculosis, and other past medical and surgical conditions. In Indian setup history of rheumatic fever and treatment for same like penicillin prophylaxis should be sought.

Family history (Socio-economic history):

Is very important for cardiovascular diseases.

Personal history:

It includes questions about diet, addictions and substance abuse, etc.

Treatment history:

Ask about all previous investigations, drugs taken, procedures done

Summary of the entire history

Analysis of history

Differential diagnosis from history

Then proceed to physical examination

I will describe each component of the above outline in my subsequent posts

So keep reading. Any feedback or suggestion is welcome

Thank you

DR. ANUPAM JENA
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