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Cardio History
 
 
Cardio History
A thorough history is vital for the diagnosis of patients with issues such as chest pain, heart failure symptoms, palpitations or syncope. The cardiovascular history may also provide important insight into patients' cardiac status, and their risk of future cardiovascular disease in the future.
 

Chest Pain

 
 

Overview

  • Chest pain is a very common presenting complaint, and the most pressing concern is to rule out life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection and tension pneumothorax. A thorough history is vital for differentiating between these causes and other less emergent conditions that may cause chest pain.

Aetiology

    • Causes of Chest Pain

    • Cardiac

    • Stable angina
    • Acute coronary syndrome - unstable angina, NSTEMI, STEMI
    • Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
    • Non-ischaemic - pericarditis, myocarditis, myocardial contusion
    • Non-Cardiac

    • Vascular - aortic dissection, pulmonary embolism
    • Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
    • Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
    • Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
    • Psychogenic - panic disorder, malingering

History of Presenting Complaint

    • Site  

      Where the pain is - central, the left or right side, the ribs, or generalised.
    • Retrosternal chest painReflux, angina
    • Pain in chest wall / ribs Suggestive of a musculoskeletal cause - unlikely to be anginal
    • Onset

      Whether the pain began suddenly or gradually, and what the patient was doing at the time.
    • Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
    • Onset during exertionSuggestive of stable angina if typical ischaemic pain
    • Onset post traumaMay represent pneumothorax or rib fractures
    • Character

       The type of pain - sharp, dull, tight, crushing, burning or tearing.
    • Central, crushing chest painTypical of acute coronary syndrome
    • Tearing pain that radiates to the backCharacteristic of aortic dissection
    • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE, chest wall pain (unlikely anginal)
    • Radiation  

      Whether the pain radiates anywhere else, such as the shoulder, arm, jaw or back.
    • Pain radiating to the shoulders / arms or jawTypical of acute coronary syndrome
    • Pain radiating to the backSuggestive of aortic dissection
    • Associated Symptoms

      Whether the pain is associated with any other symptoms.
    • Nausea, vomiting and diaphoresisSuggestive of angina / acute coronary syndrome
    • FeversSuggestive of pneumonia, pericarditis or costochondritis
    • Shortness of breathSuggestive of respiratory cause such as pneumonia, pneumothorax or PE
    • CoughSuggestive of pneumonia or reflux
    • Sour taste / acid refluxSuggestive of reflux pain
    • Timing

      How long the pain has been going on for.
    • Central crushing chest pain lasting >20 minutesSuggestive of acute coronary syndrome rather than stable angina
    • Exacerbating Factors

      Whether anything makes the pain worse, such as breathing in or sitting forward.
    • Exertional chest painSuggestive of cardiac pain
    • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE or chest wall pain (unlikely anginal)
    • Brought on with foodSuggestive of reflux
    • Worsened by sitting forward or lying downSuggestive of reflux
    • Alleviating Factors

      Whether anything they've tried has improved or resolved the pain.
    • Relief with GTNStrongly suggestive of cardiac ischaemia, though GTN may also relieve oesophageal pain
    • Relief with reflux medsMore likely to represent reflux pain
    • Relief with passing gasSuggestive of ‘pseudo-angina’ - gas in stomach or splenic flexure
    • Improved with sitting forwardSuggestive of pericarditis
    • Severity

    • How severe the pain is out of 10, with 10 being the worse possible pain.
    • How the pain is impacting the patient’s life, such as work, hobbies or even mobility.

Extra Credit

    • High Likelihood of Acute Coronary Syndrome

    • Pressure-like sensation (e.g. tight or crushing)
    • Radiating to one or both arms
    • Associated with exertion, nausea, vomiting or diaphoresis
    • Low Likelihood of Acute Coronary Syndrome

    • Stabbing pain
    • Pleuritic pain
    • Positional pain
    • Inframammary pain
    • Reproducible with palpation
Last updated on November 11th, 2017
 
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Read More...

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