CVS History of Presenting Illness (HOPI) - Complete Framework

1. CHEST PAIN / DISCOMFORT

S - Site

• Central/retrosternal = most typical for ischemia
• Left-sided, right-sided, epigastric, back
• Ask: "Can you point to where you feel it?"

O - Onset

• Sudden ("like a light switch") = acute MI, dissection, PE, arrhythmia
• Gradual, building over minutes = ACS, angina
• After meals / positional = GI/MSK cause
• Ask: "Did it come on suddenly or gradually?"

C - Character

• Tight/squeezing/pressure/heavy = ischemic (angina, MI)
• Tearing/ripping = aortic dissection
• Sharp/stabbing/pleuritic (worse on inspiration) = pericarditis, PE, pleuritis
• Burning = GORD (can mimic ischemia)
• Ask: "Can you describe the feeling? Like a heaviness, a tightness, or something else?"

R - Radiation

• To jaw, left arm, shoulder, neck = classic ischemia
• To both arms = strong predictor of MI
• To the back = dissection (ascending - chest to back; descending - back to abdomen)
• Ask: "Does it spread anywhere - your arm, jaw, neck, back?"

A - Associated symptoms

• Dyspnea - effort or rest?
• Diaphoresis (sweating) - a red flag for ACS
• Nausea/vomiting - common in inferior MI
• Palpitations - arrhythmia causing ischemia or vice versa
• Syncope - severe ischemia, VT, AS
• Haemoptysis - PE, pulmonary hypertension
• Cough - LVF, PE
• Fever/pleurisy - pericarditis, PE

T - Timing

• Duration: seconds = unlikely cardiac; minutes = angina; hours = ACS
• Frequency: first ever or recurrent?
• Does it come and go or remain constant?

E - Exacerbating and Relieving factors

• Exacerbated by exertion, relieved by rest = classic stable angina (most important CVS pattern)
• Relieved by nitrates = suggests ischemia
• Worse lying flat, relieved by leaning forward = pericarditis
• Worse after food / positional = GORD
• Ask: "Does anything make it better or worse? Exercise, rest, meals, position, deep breathing?"

S - Severity

• 0-10 scale
• Functional impact: can they walk up stairs? How far?

Key clinical rule (Harrison's): Dyspnea or chest discomfort that appears during activity and resolves with rest is characteristic of heart disease. The opposite pattern - symptoms at rest relieved by exertion - is rarely cardiac.

2. DYSPNEA (Breathlessness)

• Class I: No symptoms with ordinary activity
• Class II: Slight limitation - comfortable at rest, symptoms with moderate exertion
• Class III: Marked limitation - comfortable at rest, symptoms with minimal exertion
• Class IV: Symptoms at rest

3. PALPITATIONS

• Syncope / pre-syncope = red flag - VT, severe arrhythmia
• Chest pain during palpitations = ischemia triggered by arrhythmia
• Breathlessness
• Family history of sudden cardiac death = red flag

4. SYNCOPE / PRE-SYNCOPE (Blackouts)

5. PERIPHERAL EDEMA

• Bilateral vs. unilateral (unilateral = DVT, local cause)
• Pitting vs. non-pitting
• Does it worsen through the day and reduce overnight? (gravitational - cardiac/venous)
• Associated with facial puffiness, ascites, weight gain? (anasarca - severe biventricular failure)
• Accompanied by dyspnea and orthopnea? (biventricular failure)
• Any ankle/leg pain? (DVT)

6. ALWAYS COMPLETE THE HOPI WITH:

Risk Factor Screen (for all CVS presentations)

1. Hypertension - known? on medications? controlled?
2. Diabetes mellitus - type, duration, HbA1c control
3. Hypercholesterolaemia - known, on statins?
4. Smoking - pack years (packs/day x years), current/ex/never
5. Family history - first-degree relative with MI/angina/sudden death <55M / <65F
6. Obesity / sedentary lifestyle
7. Previous cardiac history - MI, PCI, CABG, arrhythmia, rheumatic fever, valvular disease
8. Atrial fibrillation (for stroke risk - CHA2DS2-VASc)

Functional Capacity Question

Quick Reference - Red Flags in CVS History

History of Presenting Illness

Presenting Complaints

1. BREATHLESSNESS

Clinically: Progressive exertional breathlessness over 2 weeks, with orthopnoea (3-pillow) and two episodes of paroxysmal nocturnal dyspnoea - consistent with left heart failure/pulmonary oedema.

2. COUGH

Clinically: Likely a mixed picture - dry cough partly from ramipril (well-known side effect) and partly from pulmonary congestion from fluid on the lungs.

3. CHEST PAIN / TIGHTNESS

Clinically: Classic crescendo angina progressing to rest pain - highly suspicious for Acute Coronary Syndrome (ACS). Radiation to jaw and left arm with diaphoresis and nausea are significant red flag features.

Since Admission - What Has Happened

• Troponin blood test came back raised, confirming some strain/injury to the heart muscle
• He was started on dual antiplatelet therapy (two blood-thinning tablets - aspirin and ticagrelor) and a blood thinner injection (fondaparinux)
• A chest X-ray showed fluid on the lungs
• He was given a water tablet (furosemide) through the drip to help remove the fluid
• He passed a large amount of urine and felt noticeably less breathless by the evening

• Breathlessness significantly improved - he can now walk to the bathroom without stopping
• Chest pain has not returned since the GTN in ED
• He is still on oxygen but the requirement has come down
• A heart scan (echocardiogram) was done and showed the heart's pumping is weaker than it should be
• The cardiology team reviewed him and he is listed for a coronary angiogram (a dye test to look at the heart's arteries) tomorrow

• Mr. Osei is comfortable at rest and in no pain
• Breathlessness has improved significantly but he still gets slightly short of breath on walking to the bathroom
• He is on oral medications now - aspirin, ticagrelor, furosemide, and his blood pressure is being managed
• He is anxious about the angiogram but has been consented and understands the procedure
• He is eating and drinking normally
• Urine output is good

Risk Factor Review

Summary of risk: Mr. Osei has multiple major risk factors for heart disease - poorly controlled blood pressure, poorly controlled diabetes, high cholesterol (untreated), strong family history (father died of MI at 52), overweight, and sedentary. These explain why he has developed significant coronary artery disease at 58.

Summary Paragraph (for ward round presentation)

Mr. Osei is a 58-year-old gentleman with known hypertension, type 2 diabetes, and untreated high cholesterol who presented two days ago with a 2-week history of worsening breathlessness, orthopnoea, and paroxysmal nocturnal dyspnoea, alongside a dry cough and central chest tightness that radiated to his left arm and jaw, associated with sweating and nausea. His symptoms escalated to rest pain on the morning of admission lasting over 30 minutes. Troponin was elevated, ECG showed ischaemic changes, and his chest X-ray confirmed pulmonary oedema. He has been treated with dual antiplatelets, anticoagulation, and IV furosemide with good response. He is currently comfortable at rest, breathlessness has improved, and he is awaiting coronary angiogram. He carries multiple cardiovascular risk factors including a strong family history of premature coronary artery disease.

History of Presenting Illness

Presenting Complaints

1. PALPITATIONS

• Feels dizzy and lightheaded during attacks
• Chest feels tight during the racing
• Feels short of breath
• Feels very anxious and like "something bad is about to happen"
• No chest pain radiating to the arm or jaw
• No sweating during attacks
• Has not lost consciousness during any of the earlier episodes - until last night

Clinically: Sudden onset and sudden offset, fast and regular, terminates with Valsalva - this pattern is highly consistent with a paroxysmal supraventricular tachycardia (SVT), most likely AVNRT.

2. SYNCOPE (THE BLACKOUT)

Clinically: Syncope occurring during an episode of palpitations with rapid and complete recovery and no post-ictal confusion strongly suggests a cardiac arrhythmia as the cause - the SVT triggered a haemodynamically significant drop in cardiac output. The absence of tongue biting, incontinence, and post-ictal phase makes seizure much less likely.

Since Admission - What Has Happened

• A 12-lead ECG was done immediately - it showed a normal rhythm (sinus rhythm) because her episode had stopped. However, there was a subtle finding - a short PR interval and a small extra wave at the start of the QRS complex (called a delta wave), which the doctor flagged as possibly significant
• Blood tests were taken including full blood count, thyroid function, electrolytes, and a troponin - all came back normal
• A CT scan of her head was done in view of the head injury - this was normal, no bleeding
• She was admitted to the cardiology ward for cardiac monitoring overnight

• Cardiac monitor showed one brief run of rapid regular tachycardia at 3am lasting about 90 seconds - she felt it but it resolved on its own
• The team printed the rhythm strip from the monitor - confirmed as SVT
• She did not collapse again
• No further interventions needed overnight
• She was reviewed by the cardiology registrar in the morning

• Mrs. Mensah is comfortable, alert, and in no distress
• No palpitations since the 3am episode
• Mild headache from the head injury, otherwise no pain
• She is anxious and asking when she can go home and what is causing this
• The cardiology team are arranging a formal electrophysiology review and a specialist ECG test (EP study discussion)
• She has been advised not to drive until further review, which has distressed her as she drives to work
• A beta-blocker (bisoprolol) has been started at a low dose to try to reduce the frequency of attacks in the meantime

Risk Factor Review

Key risk concern: The family history of a young sudden death (uncle at 38) is a significant red flag. Combined with the ECG finding of a possible delta wave (suggesting Wolff-Parkinson-White syndrome - an extra electrical pathway in the heart), this patient needs urgent electrophysiology assessment. WPW can cause life-threatening arrhythmias if not identified.

Summary Paragraph (for ward round presentation)

Mrs. Mensah is a 34-year-old previously well lady who presented following a syncopal episode in the context of palpitations. She gives a 3-week history of paroxysmal, sudden-onset, regular, fast palpitations lasting 5 to 20 minutes with abrupt termination, occurring with increasing frequency. Last night she lost consciousness for approximately 30 seconds during an episode, with rapid and complete recovery and no features to suggest seizure. Her admission ECG shows a possible delta wave raising the possibility of Wolff-Parkinson-White syndrome, and a brief run of SVT was captured on cardiac monitoring overnight. Bloods and CT head are normal. A significant family history of premature sudden death is noted. She has been started on bisoprolol and is awaiting urgent electrophysiology review. She has been advised not to drive pending further assessment.

Learning Points from This Case

HOPI - Shortness of Breath (Dyspnoea)

Using the 8-Point Framework

The Story in One Line First

"Mrs. Amara, 34F, came in saying 'I can't breathe properly and my heart keeps racing' - breathlessness started 3 weeks ago and is getting worse."

1. ONSET - Sudden or Gradual?

What this tells you:

• Gradual onset = cardiac failure, anaemia, lung disease
• Sudden onset = PE, pneumothorax, acute heart failure, arrhythmia
• Her breathlessness is both - gradual background + sudden during palpitation episodes = arrhythmia-triggered

2. DURATION - Short or Long?

What this tells you:

• Episodes lasting minutes that stop suddenly = arrhythmia-driven
• Persistent background breathlessness = underlying cardiac or respiratory cause
• Duration mirrors the palpitation duration - strong link confirmed

3. TIMING - Night? Morning? Day?

What this tells you:

• Nocturnal breathlessness (waking at night) = heart failure (PND) or asthma
• Any time of day with no pattern = arrhythmia or anxiety
• Early morning wheeze/breathlessness = asthma
• Her nocturnal episode was arrhythmia-triggered, not positional fluid redistribution

4. COURSE - Continuous or Episodic? Progressive?

What this tells you:

• Episodic = respiratory (asthma, COPD) or cardiac arrhythmia
• Progressive/continuous = cardiac failure, lung fibrosis, anaemia
• Getting more frequent = escalating arrhythmia burden - needs urgent investigation
• Episodic + worsening frequency = arrhythmia until proven otherwise

5. SEVERITY - How Bad Is It? NYHA Grade?

Grade the severity using the scale from your notes:

She fluctuates between Grade 1 (baseline) and Grade 4 (during severe arrhythmia episodes) - this range itself is clinically meaningful.

6. AGGRAVATING FACTORS - What Makes It Worse?

What this tells you:

• Orthopnoea (worse lying flat) = cardiac failure - she does NOT have this, which argues against heart failure
• Exertion triggering it = cardiac (angina, failure) or respiratory
• Environmental triggers / allergens = asthma
• Caffeine = can trigger SVT episodes
• Her main aggravating factor = palpitation onset = arrhythmia-driven breathlessness

7. RELIEVING FACTORS - What Makes It Better?

What this tells you:

• Position (sitting up) relieves it = heart failure (orthopnoea)
• Stops when palpitations stop = arrhythmia is driving the breathlessness
• Medication through drip = adenosine terminated SVT = confirms arrhythmia cause
• Inhaler not used / not helpful = against asthma/COPD

8. ASSOCIATED SYMPTOMS - CVS and Respiratory Review

The Sticky Summary - How to Remember This Forever

O - Onset         (sudden or gradual?)
L - Long/short    (duration)
D - Day/Night     (timing)

C - Course        (episodic or continuous, better or worse?)
A - Amount        (severity / NYHA grade)
R - Relieving &
    aggRavating   (position, exertion, allergens, meds)
S - Symptoms      (associated - CVS + respiratory review)

Every time a patient says "I can't breathe" - run through OLD CARS in your head and you will never miss a question.

One-Liner to Present on Ward Round

"Mrs. Mensah is a 34-year-old lady with a 3-week history of episodic breathlessness, sudden in onset, lasting 5 to 20 minutes, always associated with palpitations, grade 3 to 4 during episodes, relieved when the palpitations terminate, with no orthopnoea or wheeze, in the context of confirmed SVT on cardiac monitoring."

Complete HOPI Scenario - Shortness of Breath

Ruling Out Every System That Can Cause It

The Patient

Opening Statement (How He Describes It)

"Doctor, for the past three weeks I've been feeling like I can't get enough air. At first I thought I was just getting old and unfit, but it's been getting worse. Last night was the worst - I had to sit up in bed with four pillows just to breathe and I still couldn't sleep properly."

THE 8-POINT HOPI

1. ONSET

Gradual onset over 3 weeks = think cardiac failure, anaemia, lung disease Not sudden = less likely PE, pneumothorax, acute arrhythmia

2. DURATION

Continuous and persistent = progressive cardiac failure or respiratory disease Not episodic = argues against arrhythmia, asthma attacks

3. TIMING

Waking up gasping at night, relieved by sitting up = classic sign of fluid on the lungs from heart failure (PND) Not early morning wheeze = against asthma

4. COURSE

Steadily progressive = heart failure decompensating, or worsening lung disease This is a clear deteriorating trajectory - needs urgent treatment

5. SEVERITY - GRADING IT

Grade 3 moving toward Grade 4 He is breathless with minimal activity and approaching breathlessness at rest This is a medical emergency - not an outpatient problem

6. AGGRAVATING FACTORS

• "Does cold air or dust or fumes make it worse?" - "No, not really"
• "Any animals at home?" - "No pets"
• "Do you smoke or work around chemicals?" - "Never smoked"
• "Does eating a big meal make it worse?" - "A little, yes - after dinner it's particularly bad"

Worse lying flat (orthopnoea) - now needing 4 pillows = strong cardiac failure sign No allergens/triggers = against asthma Worse after meals = diaphragm pushed up by full stomach in a patient with limited reserve

7. RELIEVING FACTORS

Sitting upright and leaning forward relieves it = cardiac failure Inhaler did not help = argues strongly against asthma/COPD Rest helps but not fully = disease is now present even at rest = advanced

8. ASSOCIATED SYMPTOMS - RULING OUT EVERY SYSTEM

CARDIOVASCULAR SYSTEM

"Yes - a dull heaviness in my chest, especially at night and when I climb stairs. Not a sharp pain."

• Chest heaviness = cardiac in context ✓

"Now that you mention it, sometimes my heart feels like it's beating irregularly - jumpy. Happened a few times this week."

• Possible AF driving decompensation - flag for ECG urgently

"Yes! Both ankles have been swollen for two weeks. My socks leave deep marks. I thought it was from standing at work."

• Bilateral pitting ankle oedema = right heart failure / fluid overload ✓

"Actually yes - I've put on about 4kg in three weeks without eating more. My trousers feel tight."

• Rapid weight gain = fluid accumulation = heart failure ✓

"I feel lightheaded when I stand up quickly."

• Postural hypotension - possible low cardiac output or medication effect

RESPIRATORY SYSTEM

"Yes, a dry irritating cough, mainly at night. No phlegm. No blood."

• Dry cough at night = cardiac cough from fluid in lungs (or ACE inhibitor)

"No whistling. Just the breathlessness."

• No wheeze = against asthma, COPD

"No - the heaviness doesn't change with breathing."

• Pleuritic pain absent = against PE, pleuritis, pneumonia

"No fever. No coloured phlegm."

• Against pneumonia/infective exacerbation

"No, no, and no - I've actually gained weight."

• Against TB/malignancy

GASTROINTESTINAL SYSTEM

"My tummy has been feeling a bit full and bloated. I can't finish a full plate of food anymore."

• Abdominal bloating + early fullness = possible hepatomegaly or ascites from right heart failure ✓

"A little nausea, mainly at night."

• Venous congestion of gut and liver in heart failure

"No, stools are normal."

• Against GI malignancy causing weight gain through other mechanisms

RENAL SYSTEM

"Yes - I've been passing less urine than usual. Maybe half of what I normally would."

• Reduced urine output = reduced cardiac output to kidneys = cardiorenal syndrome ✓

"No, just the ankles."

• Facial puffiness = nephrotic syndrome - not present here

"No."

• Against renal cause of oedema

NEUROLOGICAL SYSTEM

"Very tired all the time. My wife says I seem more forgetful lately but I put that down to stress."

• Fatigue and mild confusion = low cardiac output reducing brain perfusion ✓

"No weakness in my arms or legs."

• Against stroke/TIA

"No."

• Against neurological cause

HAEMATOLOGICAL / ANAEMIA SCREEN

"My daughter says I look pale. I have been very tired for a few months actually, before the breathing got bad."

• Pallor + fatigue = possible anaemia contributing - check FBC

"Stools have been a bit darker recently now that I think about it."

• Dark stools = possible GI bleed = iron deficiency anaemia - RED FLAG - needs urgent investigation

"I take aspirin daily - I've been on it for years."

• Aspirin + dark stools = possible GI bleed ✓ - flag immediately

THYROID / METABOLIC

"No - if anything I feel cold more than usual."

• Against hyperthyroidism as a cause of high-output failure

"Come to think of it, I drink a lot of water and go to the toilet a lot."

• Possible undiagnosed diabetes - check blood sugar

MUSCULOSKELETAL

"My knees ache a bit but I put that down to age."

• Against rheumatological cause of cardiac disease (but note for full picture)

Risk Factor Review

What the Systems Review Has Built

Summary Paragraph - Ward Round Ready

Mr. Asante is a 62-year-old gentleman with known but untreated hypertension who presents with a 3-week history of gradually progressive breathlessness, now grade 3 to 4, with orthopnoea requiring 4 pillows, paroxysmal nocturnal dyspnoea, bilateral ankle oedema, 4kg weight gain, reduced urine output, and a dry nocturnal cough. Systems review is notable for possible new AF on history, dark stools in the context of aspirin use raising concern for GI bleeding and anaemia, symptoms of possible undiagnosed diabetes, and fatigue suggesting low cardiac output. He stopped his antihypertensive medication 2 years ago. The overall picture is consistent with decompensated heart failure, likely hypertensive in aetiology, with several compounding factors requiring urgent investigation including ECG, FBC, renal function, BNP, glucose, and chest X-ray.

The Trick to Remember

When someone says "I can't breathe" - don't just think lungs. Run through every system asking one simple question each:

• Heart saying it? = orthopnoea, oedema, weight gain
• Lungs saying it? = wheeze, pleuritic pain, phlegm
• Blood saying it? = pallor, fatigue, bleeding
• Kidneys saying it? = swelling, less urine
• Thyroid saying it? = heat intolerance, tremor, weight loss
• Gut saying it? = bloating, dark stools

Mr. David Asante - HOPI in Paragraph Form