History

Presenting Complaint 

The reason the patient has sought medical attention. Most common in cardiovascular disease are chest pain, dyspnoea (breathlessness), palpitations and syncope (dizziness).

History of Presenting Complaint 

Explore features of the presenting complaint (e.g. onset, progression, severity; Figure 32a).

• Dyspnoea: the commonest symptom of heart disease. Establish whether it occurs at rest, on exertion, on lying flat (orthopnoea) or at night. Determine rate of onset (sudden, gradual). Dyspnoea due to pulmonary oedema (heart failure) may cause sudden wakening (paroxysmal nocturnal dyspnoea, PND), a frightening experience in which the patient wakes at night, gasping for breath.
  
• Chest pain ‘SOCRATES’
  
  Site: where is it? Onset: gradual, sudden? Character: sharp, dull, crushing? Radiation: to arm, neck, jaw? Associated symptoms: dyspnoea, sweating, nausea, syncope or palpitations? Timing: duration of the pain? Is it constant or does it come and go? Exacerbating and relieving factors: worse/better with breathing, posture? Severity: does it interfere with daily activities or sleep?
  
  Angina is described as crushing central chest pain, radiating to left arm/shoulder, back, neck or jaw. Pain due to pericarditis is sharp and severe, aggravated by inspiration, and is classically relieved by leaning forward.
  
• Palpitations: increased awareness of the heart beat. Ask patient to tap out the rhythm. Premature beats and extrasystoles give sensation of missed beats.
  
• Syncope: commonly vasovagal, provoked by anxiety or standing for extended periods of time. Cardiovascular syncope is usually due to sudden changes in heart rhythm; for example, heart block, paroxysmal arrhythmias (Stokes–Adams attacks).
  
• Others: fatigue – heart failure, arrhythmias and drugs (e.g. β-blockers). Oedema and abdominal discomfort – raised central venous pressure (CVP), heart failure. Leg pain on walking may be due to claudication secondary to peripheral vascular disease.

Past Medical History 

Previous and current conditions. Ask about myocardial infarction (MI), stroke, hypertension, diabetes, rheumatic fever. Also recent blood pressure measurements and lipid levels, and any investigations.

Drug History 

Prescribed and over-the-counter medications. Ascertain compliance. Ask about drug allergies and their effect(s).

Family, Occupational and Social History 

Family history of MI, hypertension, diabetes, stroke or sudden death? Smoking including duration and amount and alcohol consumption. Occupation: stress, sedentary or active.

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