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1. History Taking in Cardiovascular System
“Always listen
to the patient
they might be
telling you the
PREPARED BY DR. RUQAYA AL-KATHIRY
HEAD OF THE MEDICAL DEPARTMENT OF UST

2. SYMPTOM ANALYSIS IN CVS:
I)CHEST PAIN:
N.B: The severity of discomfort doesn't correlate to the severity of the cardiac problem nor
prognosis.
TYPES OF CARDIAC CHEST PAIN:
1-Angina
2-Myocardial Pain
3-Pericardiatic Pain
4-Dissecting Aneurysm
ASSIGNMENT: Q.WHAT IS THE COMMONEST CAUSE OF CARDIAC PAIN?
1-ANGINA:
-SITE: retrosternal (characteristic)
-CHARACTER: *tight band around the chest
*feeling of constriction/heaviness
*discomfort
*wind
-RADIATION: *neck
*jaw
*ear
*back
*epigastrium
-REFERRED:*1 or both arm, hand or wrist (on ulnar aspect of the left). Q.WHY?

3. -SEVERITY: mild to moderate severity
-DURATION: 2-10 min.
-AGGRAVATING FACTORS:*exertion (characteristic)
*emotions
*cold weather
*walking after meal
-RELIEVING FACTORS:*rest(characteristic)
*peace
*warm weather
*warming up before exercise
*drugs: nitrates (NTG)
-ASSOCIATED SYMPTOMS:*breathlessness
*feeling of wind
*belching
Q.WHAT ARE THE 3 CHARACTERISTICS OF ANGINAL PAIN?
ASSIGNMENT: Q.DEFINE:UNSTABLE,CRESCENDO &NOCTURNAL(DECUBITUS) ANGINA.
2-MYOCARDIAL INFARCTION (MI):
N.B: Site, Character and Radiation are similar in angina but differs in:
-SEVERITY: very severe (may be silent) ASSIGNMENT: Q.CAUSES OF SILENT MI?
-DURATION: persists at rest
-AGGRAVATING FACTORS: often no obvious ppt. factor i.e. spontaneous.
-RELIEVING FACTORS: not relieved by rest nor NTG
-ASSOCIATED SYMPTOMS: ↑sympathetic activity. ASSIGNMENT: Q.WHAT ARE
AUTONOMIC SYMPTOMS THAT ARE ASSOCIATED WITH MI?

4. 3-PERICARDITIC PAIN:
-SITE: retrosternal; or toward cardiac apex
-CHARACTER:*sharp, stabbing pain
*soreness / raw
*rarely tight / heavy (pericardial effusion)
-RADIATION:*left shoulder & upper arm
*back
-SEVERITY :*fluctuates in intensity.
-DURATION: hrs. to d
-AGGRAVATING FACTORS:*change in posture
*inspiration
-RELIEVING FACTORS:*by analgesics (NSAIDS); by sitting up & leaning forward
*not relieved by rest
-ASSOCIATED SYMPTOMS:*pericardial rub
ASSIGNMENT: Q.HOW TO DIFFERENTIATE B/W PERICARDIAL & PLEURAL PAIN
CLINICALLY?
4-DISSECTING ANEURYSM:
-SITE: *interscapular (b/w shoulder blades) firstly
*retrosternal
*neck
*abdomen
-CHARACTER: tearing or ripping sensation (knife-like)
-RADIATION: no radiation

5. -SEVERITY: sudden, very severe
-DURATION: persistent
-AGGRAVATING FACTORS: follows a sudden twist or exertion
-RELIEVING FACTORS: no relieving factors; restless with pain
-ASSOCIATED SYMPTOMS:*weakness in the legs
*asymmetric pulses
*unexpected bradycardia
ASSIGNMENT: Q.WHAT ARE THE PREDISPOSING FACTORS FOR AORTIC DISSECTION?
The 2 commonest central non-cardiac chest pains which can be mistaken for angina
are:
1-Musculoskeletal Chest Pain:
*The pain may vary with posture movement.
*Local tenderness on localized pressure over a rib/costal cart.
2-Oesophageal Disease:
A-Oesophageal Spasm:
*Site : retrosternal
*Character Pressure, tightness, burning:
*Radiation: sometimes radiates to arm.
*Severity : often wakes the pt. from sleep.
*Duration: 2–30 min
*Aggravating factors: exertion; often present at other times.
*Relieving factors: antianginal Rx such as S/L nifedipine, nitrates ; not by rest.

6. B-Oesophageal Reflux:
*Site : Substernal, epigastric.
*Character: Burning
*Duration: 10–60 min
*Aggravating factors: postprandial recumbency, alcohol, aspirin, or some foods.
*Relieving factors: relieved by antacids.
ASSIGNMENT: Q.WHAT ARE THE 2 COMMONEST CAUSES OF NON-CARDIAC CENTRAL
CHEST PAIN?

7. II)DYSPNOEA:
Q. DEFINE DYSPNOEA.
Q.WHAT ARE THE CAUSES OF DYSPNOEA? CVS causes of ac. S.O.B:HF,MI, PE & arrhythmias.
Types:
-Exertional Dyspnoea: occurs at exercise levels below those expected for the pt.’s age
and level of fitness (see the table).
-Paroxysmal Nocturnal Dyspnoea(Cardiac Asthma): Q.DEFINE? Characteristically, the
pt. sits up gasping for breath, has a wheezy cough with sputum. It is a feature of ac.
L.S.H.F.
ASSIGNMENT: Q. HOW TO DIFFERENTIATE PND FROM B.A?
-Orthopnoea: Q.DEFINE? It is a later feature than PND thus a sign of advanced HF. It is
generally relieved by sitting upright or by sleeping with additional pillows.
ASSIGNMENT: Q. HOW CAN THE SEVERITY OF ORTHOPNOEA BE GRADED?
-Dyspnoea at rest.
-Platypnoea: S.O.B that is relieved when lying down & worsens when sitting or
standing up. It is the opposite of orthopnoea.
-Trepopnoea: S.O.B that is sensed while lying on 1 side but not on the other. Pts. with
pleural effusion lie on the affected side while those with chr. HF prefer to lie mostly on
the left side. WHY?

8. Grades of Dyspnoea:
S.O.B on unaccustomed exertion (strenuous exercise)=NL
Grade 0
Slight limitation of activity (when walking up an incline/hurrying on the same level)
Grade І
Moderate limitation of activity (walks slower than most on the level/stops after 15 min.
of walking on the level)
Grade ІІ
Marked limitation of activity (stops after a few min. of walking on the level)
Grade ІІІ
S.O.B at rest (such as getting dressed)
Grade ІѴ
III)PALPITATION:
Definition: “an AbNL awareness of the heartbeat.”
*Ask the following questions:
Q.WHAT DO YOU MEAN BY PALPITATION? CAN YOU TAP OUT ON THE TABLE HOW
YOUR HEART BEATING IS WHEN YOU HAVE AN ATTACK?
-Missed heart beat (recurrent but short-lived)=Vent./Atrial extrasystole (Ectopic Beats)
-Heart jumping about/racing (rapidly & irregularly)=Atrial Fibrillation(AF)
-Heart racing or fluttering=Supraventricular tachycardia(SVT)
Q.IS IT CONTINOUS OR INTERMITTENT? Sustained or paroxysmal
Q.IS IT REGULAR OR IRREGULAR?
N.B: AF commonly causes an irregular heartbeat in the elderly but rarely causes palpitation.
Q.HOW IS ITS ONSET AND TERMINATION? sudden or gradual
Q.HOW FREQUENT & HOW LONG DOES AN ATTACK LAST? lasts for mins. or hrs.
Q.HOW FAST DOES IT GO? Rapid or slow
Q.HAVE YOU NOTICED ANYTHING WHICH SETS IT ON/OFF? Ppt. factors (exercise, anxiety,
alcohol, caffeine, recreational or other drugs)/relieving factors (breath-holding)

9. Q.DO YOU GET OTHER SYMPTOMS WITH THE ATTACK? Chest discomfort, S.O.B, polyuria,
presyncope, syncope.
ASSIGNMENT: Q.WHICH PTS. ARE AT PARTICULAR RISK OF VENT. ARRHYTHMIAS?
IV)OEDEMA:
Definition: “It is tissue swelling due to excess ECF”
*The pt. may complain of swelling of the ankles or feet.
*Oedema in the absence of other symp. as S.O.B is an uncommon presentation.
*Ask the following questions:
Q.HOW WAS THE ONSET,COURSE,DURATION?
Q.THE SITE OF ITS APPEARANCE?GENERALISED OR LOCALISED?
*When it is generalised its distribution is determined by gravity.
• Semirecumbent pt.= legs, back of thigh, lumbosacral area.
• Lying flat= face and hands.
*When localised it may be due to the following causes:
• Venous =DVT
• Lymphatic=lymphoedema
• Inflammatory=injury, infection, ischaemia or chemicals
• Allergic=angioedema.
Q.IS IT UNILATERAL OR BILATERAL?
ASSIGNMENT: Q.WHAT ARE THE CAUSES OF BOTH?
ASSIGNMENT: Q.HOW TO DIFFERENTIATE BETWEEN THE CARDIOGENIC CAUSE
OF OEDEMA AND OTHER CAUSES?
Q.WHEN DOES IT OCCUR?IS IT WORSE IN THE MORNING OR NIGHT?

10. V)CARDIAC DISEASE PRESENTING WITH NON-CARDIAC SYNPTOMS:
CAUSE
SYMPTOM
SYSTEM
*Arrhythmia
*Postural Hypotension (ASSIGNMENT: Q.DEFINE.WHAT
ARE THE CAUSES OF POSTURAL HYPOTENSION?)
*Neurocardiogenic syncope
*Mechanical obstruction to C.O: severe AS, HOCM,
PE, myxoma (rare)
Syncope
CNS
*Cerebral Embolism from the heart: MS, AF, LV
mural thrombus post-MI, aortic atherosclerotic plaque
*IE: vegetation of MR & AR
*HT: H, blurring of vision, tinnitus, vertigo, epistaxis
Stroke
ASSIGNMENT: Q.WHERE ARE
THE COMMON SITES FOR
SYSTEMIC EMBOLIZATION?
*Liver Congestion 2ary to HF; mesenteric embolism
*GIT Congestion 2ary to HF
Abdominal Pain
Dyspepsia
GIT
*Artificial Valves
*Hepatic congestion as in R.S.H.F, (Q.WHAT IS COR
PULMONALE?) TS, TR, pericardial effusion,
constrictive pericarditis
*Marked liver congestion, compression of the bile
canaliculi & inspissation of bile in them
N.B: Associated viral hepatitis is the commonest
Jaundice=-Pre-Hepatic
(Haemolytic)
-Hepatic
(Hepatocellular)
-Post-Hepatic
(Obstructive)
Q.WHAT ARE THE CAUSES OF J
IN CARDIAC DISEASES?
HF due to ↓C.O
Oliguria
RENAL
N.B: IE may present with non-specific symptoms including weight loss, tiredness & night sweats.

11. VI)COUGH:
Q.DEFINE?
*Ask the pt. the following:
Q.ASK ABOUT THE ONSET,COURSE AND DURATION?
Q.IS IT DRY OR PRODUCTIVE?
Q.IF PRODUCTIVE, ASK ABOUT THE VOLUME,COLOUR AND SMELL OF THE SPUTUM.
Q.DOES IT OCCUR AT A SPECIFIC TIME OR POSTURE?
Q.ARE THERE ASSOCIATED SYMPTOMS?.
Q.ASK ABOUT CIGARETTE SMOKING,EXPOSURE TO IRRITANT, HX. OF ALLERGY?
VII)HAEMOPTYSIS:
Q.DEFINE?
Q. DIFFERENTIATE B/W HAEMOPTYSIS & HAEMATEMESIS?
-Pulmonary Oedema
-Mitral Stenosis
-Hypertension
-Drugs: ACO

12. PAST HISTORY:
-Ask about rheumatic fever or heart murmurs during childhood.
-Ask about conditions associated with heart disease, including:
*Smoking
*HT
*D.M
*Kidney disease
*Thyrotoxicosis (AF)
*Alcohol intake (arrhythmias & CMP)
*Marfan's syndrome (aortic regurgitation or aortic dissection).
ASSIGNMENT: Q.WHAT ARE THE IMPORTANT QUESTIONS TO ASK IN RELATION TO IE?
-Consider possible links b/w other organ system diseases and CV illness: e.g,
*RF or disseminated CA=pericardial effusion
*Cytotoxic drugs=HF
*Radiotherapy=radiation arteritis in the affected area
*Chr. Resp. dis.=R.S.H.F (cor pulmonale) or AF
*CTD such as RA=Raynaud's phenomenon & pericarditis
FAMILY HISTORY:
*In a pt. with known or suspected cardiovascular dis. (CVD), particular attention should
be directed to the family Hx. Familial clustering is common in many forms of heart dis.

13. Single-gene defects: with AD/AR expression may occur, as in:
*Hypertrophic cardiomyopathy (HOCM=sudden unexplained death at a young age)
*Marfan’s syndrome (Aortic Dissection)
*Prolonged QTsyndrome (Inherited arrhythmia=sudden unexplained death; young age)
*Familial Hypercholestrolaemia (associated with premature C.A.D & P.A.D)
*Polycystic kidney disease (PCK)
*Myotonic dystrophy
*Ehlers-Danlos Syndrome
*Holt-Oram Syndrome
*Factor V Leiden Deficiency (Inherited thrombophilia=peripheral art.&ven. thrombosis)
Polygenic disorders: due to the interaction of several genes:
*Premature Coronary Disease (in a 1st-degree relative (<60ys in a ♀ / <55ys in a ♂)
*Essential Hypertension
*Type 2 Diabetes Mellitus (T2DM)
*Hyperlipidemia (the most important risk factors for C.A.D).
*Rheumatic Heart Disease (RHD)
*Abdominal Aortic Aneurysm (AAA)
Familial clustering of CVD may also be related to familial dietary or behavior patterns:
-excessive ingestion of salt & calories
-cigarette smoking.
N.B: Remember that asking about family Hx may inc. the pt’s anxiety about their own health &
that of their children.

14. SOCIAL HX:
-Smoking is the strongest reversible risk factor for CAD & PVD.
*Ask smokers: how long, what (cigarettes, cigars or pipe) and how much.
Use 'pack years' to estimate the risk of tobacco-related health problems.
*Ask non-smokers: passive smoking at work or home.
-Alcohol can induce AF & alcohol excess=obesity, HT & dilated CMP. Excess alcohol
intake with poor nutrition=peripheral art. & venous disease.
- I.V.D.U can damage peripheral art. & veins, most commonly causing an infected
false aneurysm of the common femoral art. in the groin: a potential source for IE.

15. OCCUPATIONAL Hx:
*Occupational illness affecting the heart is relatively uncommon.
*Heart disease may impair physical activity & affect employment. This may be a
source of anxiety and an indication for Rx.
*Dx of heart dis. has medicolegal consequences in commercial drivers & pilots.
*Workers exposed to occupational vibration through the use of air-powered tools may
develop 'vibration white finger', which presents with vasospastic (Raynaud's
phenomenon) and neurosensory (numbness, tingling) symptoms.
Occupational exposure associated with cardiovascular disease
Arrhythmias, CMP
Organic Solvents
Raynaud’s Phenomenon
(ASSIGNMENT:Q.DEFINE)
Vibrating Machine Tools
Alcoholic CMP
Publicans
Occupational exposure exacerbating pre-existing cardiac disease
Angina, Raynaud’s Disease
Cold exposure
Embolism through foramen ovale
Deep-sea Diving
Occupational requirements for high standards of cardiovascular fitness
Pilots
Public transport/heavy goods drivers
Armed Forces
Police

16. DRUG HISTORY:
*A complete list of all medication, both prescribed & obtained OTC is essential.
*Some imp. associations b/w medication and symp. consistent with cardiac dis. are
listed below.
SYMPTOMS RELATED TO MEDICATION
β-blockers in pts with B.A
Exacerbation of HF by β-blockers, Ca+² antagonists, NSAIDs
DYSPNOEA
Starting thyroxine for hypothyroidism may ppt. or aggravate angina
'Recreational' drugs (cocaine & amphetamines) can cause arrhythmias, chest
pain and even MI
NSAIDs
Oesophageal pain from medication e.g. tetracycline
Oesophageal reflux ↑ by nitrates, calcium antagonists
CHEST PAIN
Fluid retention from corticosteroids, NSAIDs
Oedema from Ca˖² antagonists e.g. nifedipine (?)
OEDEMA
Tachycardia ± arrhythmia from sympathomimetics (ephedrine) salbutamol,
methylxanthines (aminophylline), digoxin toxicity, ↓K+¹ from diuretics
PALPITATION
ACEIs, Calcium Channel Blockers
SYNCOPE
β-blockers may worsen the symptoms
INTERMITTENT
CLAUDICATION
N.B: Ask about alternative medicine & herbal remedies, as these may contain ingredients with
cardiovascular actions.

17. “Medicine is learned
at the bedside
and not in the
classroom”
Sir William Osler (1849-1919)
THANK YOU FOR YOUR ATTENDANCE