Cardiovascular- History Collection
History of presenting complaint
Patients with cardiovascular pathology can present with a wide variety of symptoms including but not
limited to, chest pain, dyspnoea, palpitations, syncope, oedema and fatigue.
The SOCRATES acronym (explained below) is a useful tool that you can use to explore each of the
patient’s presenting symptoms.
Key cardiovascular symptoms
Symptoms that are typically associated with cardiovascular disease include:
Chest pain: typically central or left-sided (e.g. pericarditis) and may radiate to the left arm
and jaw (e.g. acute coronary syndrome). In some cases, patients having a myocardial
infarction may complain of neck pain rather than chest pain.
Dyspnoea: shortness of breath which may be exertional, related to lying down (orthopnoea)
or wake the patient from sleep (paroxysmal nocturnal dyspnoea).
Palpitations: a sensation of a fast-beating, fluttering or pounding heart that may feel regular
or irregular. It can be useful to ask the patient to tap out the rhythm to assess its regularity.
Syncope: rapid onset loss of consciousness (LOC) secondary to reduced cerebral perfusion.
The LOC is typically short in duration with the patient recovering spontaneously. Syncope
may be associated with sudden changes in posture (e.g. postural hypotension), exertion
(e.g. aortic stenosis) or occur randomly (e.g. arrhythmia).
Oedema: fluid retention in the tissues which may be peripheral (e.g. pedal oedema) or central
(e.g. sacral oedema). In the context of a cardiovascular history, the cause of oedema is
most likely to be congestive heart failure or a side effect of medications such as
amlodipine.
Intermittent claudication: muscle pain, typically in the calf, that develops during mild
exertion and resolves upon resting. Intermittent claudication is caused by inadequate
arterial supply secondary to peripheral vascular disease.
Systemic symptoms: these can include fatigue (e.g. congestive heart failure), fever (e.g.
pericarditis, endocarditis), weight loss (e.g. endocarditis, atrial myxoma) and weight gain
(e.g. congestive heart failure).
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in
more detail. It is most commonly used to explore pain, but it can be applied to other symptoms,
although some of the elements of SOCRATES may not be relevant to all symptoms.
Site
Ask about the location of the symptom:
“Where is the pain?”
“Can you point to where you experience the pain?”
Onset
Clarify how and when the symptom developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“What were you doing when the pain started?”
“How long have you been experiencing the pain?”
Character
Ask about the specific characteristics of the symptom:
“How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
“Is the pain constant or does it come and go?”
Radiation
Ask if the symptom moves anywhere else:
“Does the pain spread elsewhere?”
“Have you noticed the chest pain spreading towards your arm, back or neck?”
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom:
“Are there any other symptoms that seem associated with the pain?” (e.g. fever in
pericarditis, weight gain in heart failure)
Time course
Clarify how the symptom has changed over time:
“How has the pain changed over time?”
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
“Does anything make the pain worse?” (e.g. exertion in angina, lying flat in pericarditis)
“Does anything make the pain better?” (e.g. glyceryl trinitrate in angina, leaning forwards in
pericarditis)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve
ever experienced?”
You can also ask how far a patient is able to walk (either on the flat or at an incline) without having to
stop before they experience chest pain or significant breathlessness to get an idea of their current
performance status.
Cardiovascular risk factors
When taking a cardiovascular history it’s essential that you
identify risk factors for cardiovascular disease as you work through the patient’s history (e.g. past
medical history, family history, social history).
Important cardiovascular risk factors include:
Hypertension
Hyperlipidaemia
Diabetes
Family history of cardiac disease
Smoking
Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which
may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify
symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of
experience.
Some examples of symptoms you could screen for in each system include:
Systemic: fevers, weight change, fatigue
Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
Genitourinary: oliguria, polyuria
Neurological: visual changes, motor or sensory disturbances, headache
Musculoskeletal: chest wall pain, trauma
Dermatological: rashes, ulcers
Past medical history
Ask if the patient has any medical conditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to
assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also
important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. coronary artery bypass
grafts, coronary artery stents, heart valve replacements):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Allergies
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance
(e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medical conditions relevant to cardiovascular disease include:
Hypertension
Hyperlipidaemia
Angina
Myocardial infarction
Obesity
Chronic kidney disease
Atrial fibrillation
Stroke
Peripheral vascular disease
Rheumatic fever
Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter
medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side effects from their medication:
“Have you noticed any side effects from the medication you currently take?”
Medication examples
Medications commonly prescribed to patients with cardiovascular disease include:
Beta-blockers (e.g. atrial fibrillation)
Calcium channel blockers (e.g. hypertension)
ACE inhibitors (e.g. hypertension)
Diuretics (e.g. congestive heart failure)
Statins (e.g. coronary artery disease)
Antiplatelets (e.g. coronary artery disease)
Anticoagulants (e.g. atrial fibrillation, artificial heart valve)
Glyceryl trinitrate spray (e.g. angina)
Some over the counter drugs which may impact the cardiovascular system include:
NSAIDs
Aspirin
Family history
Ask the patient if there is any family history of cardiovascular disease:
“Do any of your parents or siblings have any heart problems?”
Clarify at what age the cardiovascular disease developed (disease developing at a younger age is
more likely to be associated with genetic factors):
“At what age did your father suffer his first heart attack?”
“When was your mother first diagnosed with high blood pressure?”
If one of the patient’s close relatives are deceased, sensitively determine the age at which they
died and the cause of death:
“I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
“Do you remember what medical condition was felt to have caused his death?”
If the patient reports unexplained sudden deaths in young relatives, consider the possibility
of cardiac channelopathies (e.g . Brugada syndrome, long QT syndrome).
Social history
Explore the patient’s social history to both understand their social context and identify
potential cardiovascular risk factors.
General social context
Explore the patient’s general social context including:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are
any adaptations to assist them (e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g.
self-hygiene, housework, food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular
risk profile:
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Diet
Ask if the patient what their diet looks like on an average day. Take note of unhealthy foods which
are known to contribute to cardiovascular disease (e.g. high salt intake, high saturated fat intake).
Exercise
Ask if the patient regularly exercises (including frequency and exercise type).
Occupation
Ask about the patient’s current occupation:
Assess the patient’s level of activity in their occupation (sedentary jobs are associated with
increased cardiovascular risk).
If the patient is experiencing episodes of syncope and works with heavy machinery or
at heights, it is important to advise them to take time off work until they have been
fully investigated.
Assessment of The Neck Vessels:
The most important observation to be made in the neck region is the assessment of jugular venous
pulse. From the jugular veins you can estimate central venous pressure (CVP) and estimate the
heart’s efficiency as a pump.
At a glance, if the patient is sitting in the supine position at 45 degrees or higher, you should not be
able to see jugular venous pulsations unless there is underlying pathologyt Assessment of The Neck
Vessels
Auscultation :
When auscultating, ensure your room is quiet, auscultate over bare skin, and listen to one sound at a
time. Your bell or diaphragm should be placed on your patient’s skin firmly enough to leave a slight
ring on their skin when removed. Be aware that your patient’s hair may also interfere with true
identification of certain sounds. The diaphragm is used to listen to high‐pitched sounds and the bell
is best used to identify low‐pitched sounds (Kaplow & Hardin, 2007). Also, remember to clean your
stethoscope between patients. Auscultate the carotid arteries in persons middle aged or older, or
those with a history of cardiovascular disease. You are listening for the presence of a bruit, which is a
blowing or swishing sound, indicating turbulent blood flow. You may need to ask your patient to
hold their breath for a short time so that you do not confuse tracheal breath sounds with a bruit.
Palpation :
Palpate the carotid arteries very gently and never at the same time. Feel the contour and amplitude
of the pulse. Normally, the contour is smooth with a rapid upstroke and normal strength (+2).
Findings should be similar bilaterally.
Circulatory Assessment:
Inspection :
Areas for evaluation you may inspect include skin color, location of any lesions, bruises or rash,
symmetry of motion, size of body parts, and any abnormal findings, sounds, and odors.
Begin by inspecting the patient’s skin for color, warmth, and moisture. Cool, clammy skin results
from vasoconstriction. Warm, moist skin results from vasodilation.
Flushing of a patient’s skin may be due to medications, excess heat, anxiety, or fear.
Pallor can result from anemia or increased peripheral vascular resistance caused by atherosclerosis.
Dependent rubor (redness) may be a sign of chronic arterial insufficiency.
Peripheral cyanosis may cause a bluish discoloration to the lips and extremities.
Inspect the oral mucous membranes for cyanosis that may not be readily apparent on the skin.
Examine underneath the tongue, inside the cheeks, and the nail beds for signs of peripheral
cyanosis.
There are two types of cyanosis that may occur in compromised patients: central and peripheral.
Central cyanosis is consistent with reduced oxygen intake or transport from the lungs. Peripheral
cyanosis suggests constriction of the peripheral arteries. This is usually from stress, cold, or anxiety.
It may also be from hypovolemia, shock, or vasoconstrictive diseases.
Note the presence of any edema. Inspect your patient’s hair distribution on their skin. Lack of hair
may also indicate arterial insufficiency.
Edema can result from many disease processes including heart failure, liver failure, or by venous
insufficiency, varicosities, and thrombophlebitis.
Auscultation
Auscultate your patient’s blood pressure.
The systolic reading reflects the pressure exerted by the left ventricle during contraction.
The diastolic reading reflects the pressure in the arteries when the heart is at rest.
Blood pressure is lowest in the newborn, and rises with age, weight gain, stress, anxiety, and during
exercise.
When auscultating blood pressure, be sure to choose an appropriate size cuff to avoid false readings.
Some helpful hints when assessing blood pressure include:
• Never take a blood pressure in an arm on the same side as a mastectomy.
• Never take a blood pressure in an arm with an arteriovenous fistula or shunt, or in an arm with a
peripherally inserted central catheter.
• If either the systolic BP is over 140 or the diastolic pressure is over 90 on repeated
measurements, the patient is considered to have Stage 1 Hypertension (high blood pressure).
• Hypertension is risk factor for heart disease, stroke, and kidney disease.
Blood Pressure Classification in Adults
Blood Pressure Classification in Adults
Category Systolic Diastolic
Normal <120 <80
Pre‐Hypertension 120-139 80-89
Stage I Hypertension 140- 159 90-99
Stage II Hypertension > 160 >100
: Palpation
The next part of the circulatory system examination is palpation. Begin by palpating the peripheral
arteries. These include the brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial.
Note the contour and amplitude of each pulsation. These should feel similar bilaterally. As you
move away from the core of the body, you may notice that the contour or upstroke of the pulsation
is less rapid. This is normal, but it is important to assess that the arteries have similar strength
bilaterally.
Auscultation
Before you begin your auscultation of the precordium, preface your exam by telling the patient you
will be listening in many different places for what might be a while.
Then, you must identify the areas you need to ausculate. You may want to inch your stethoscope in
a “Z‐pattern” across the precordium, from the base of the heart to the apex.
Concentrate to the sound of the “lub” and the “dub.” The “lub” or first heart sound is known as S1.
The “dub” or the second heart sound is known as S2.
Heart Sounds: S1 S1, the “lub” of the “lub‐dub,” is produced by the closure of tricuspid and mitral
valves.
Alterations you may auscultate that involve S1 are as follows:
• S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis.
• S1 is diminished in first degree heart block.
• S1 split is most audible in tricuspid area (T‐lub‐dubHeart Sounds: S2 S2, the “dub” of the “lub‐
dub,” is produced by the closure of aortic & pulmonic valves. Alterations you may auscultate that
involve S2 are as follows:
• Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (“lub‐ T‐
dub, lub‐dub”).
• Splitting of S2 sound can occur when the aortic and pulmonary valves do not close at the same
time .
This can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, or left bundle
branch block.
Heart Sounds: S3 The third heart sound is produced by the rapid filling of the ventricle (that is not
completely empty) during early diastole S3 is also known as a ventricular gallop (“lub‐DUB‐ta” or
“Ken‐tuc’‐ky”).
S3 is normal in pregnancy, children, adults less than thirty years old, during exercise, anxiety, or
anemia. It is heard best at the apex in the left lateral decubitus position, using the bell. Pathologic
S3 occurs in people over the age of 40, usually due to myocardial failure.
Heart Sounds: S4 The fourth heart sound is typically heard in late diastole before S1, as a result of
increased ventricular resistance to atrial filling, due to either decreased ventricular compliance or
increased ventricular volume. It is low pitched and best heard with the bell.
S4 is also known as an atrial gallop (“ta‐lub‐DUB” or ”Tenn‐es‐see”). S4 is often normal in older
adults and is heard best at the apex in the left lateral decubitus position.
Pathological S4 may be caused by coronary artery disease, hypertension, cardiomyopathy, or aortic
stenosis.
