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CVS CASE SHEET — DETAILED HISTORY TAKING FOR MEDICINE POSTINGS

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PART I: PATIENT IDENTIFICATION

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PART II: CHIEF COMPLAINTS

1. _____________________________ — since ___
2. _____________________________ — since ___
3. _____________________________ — since ___

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PART III: HISTORY OF PRESENTING ILLNESS (HOPI)

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A. CHEST PAIN / DISCOMFORT

• Onset: Sudden / Gradual
• Duration: Minutes / Hours / Continuous
• Character: Pressure / Squeezing / Burning / Tearing / Stabbing / Dull ache / Heaviness
• Site: Retrosternal / Precordial / Left-sided / Back / Epigastric
• Radiation: Neck / Left shoulder / Left arm / Both arms / Jaw / Back / Abdomen
• Severity: (0–10 scale)
• Precipitating factors: Exertion / Emotion / Cold / Meals / Rest
• Relieving factors: Rest / Sublingual nitrates (response time) / Antacids / Posture (pericarditis — leaning forward)
• Aggravating factors: Deep inspiration (pleuritic) / Palpation (musculoskeletal) / Swallowing (esophageal)
• Associated symptoms: Sweating / Nausea / Vomiting / Dyspnea / Syncope / Palpitations / Fever

Differentiating features:

• Stable angina: Exertional, relieved within 5 min by rest/nitrates
• Unstable angina/NSTEMI: Rest pain or crescendo pattern, may not resolve quickly
• STEMI: Severe, prolonged (>20 min), not relieved by nitrates
• Aortic dissection: Sudden, severe, tearing, radiates to back; ascending → anterior chest, descending → back radiating to abdomen
• Pericarditis: Sharp, pleuritic, relieved by leaning forward, associated pericardial rub
• Pulmonary embolism: Pleuritic, with dyspnea and hemoptysis (Goldman-Cecil, p. 2503–2505)

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B. DYSPNEA

• Onset and duration
• Grade (NYHA Functional Classification):

• Type of dyspnea:
  • Exertional dyspnea — quantify exercise tolerance (number of stairs, distance on flat)
  • Orthopnea — dyspnea on lying flat; number of pillows used; onset after lying down
  • Paroxysmal Nocturnal Dyspnea (PND) — wakes from sleep breathless, relieved sitting upright; duration before relief
  • Dyspnea at rest
  • Cardiac asthma — wheeze associated with pulmonary congestion

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C. PALPITATIONS

• Onset: Sudden or gradual
• Offset: Sudden or gradual
• Character: Fast / Slow / Regular / Irregular / Missed beats / Forceful beats / Fluttering
• Duration of each episode
• Frequency
• Associated symptoms: Presyncope / Syncope / Chest pain / Dyspnea / Polyuria (after SVT — vagal response)
• Precipitating factors: Exertion / Coffee / Alcohol / Stress / Medications
• Termination: Spontaneous / Valsalva / Carotid sinus massage / Hospital visit

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D. SYNCOPE / PRESYNCOPE

• Onset: Sudden (cardiac arrhythmia) vs. Prodromal (vasovagal)
• Posture at time of event
• Precipitating factors: Exertion (AS, HOCM, pulmonary hypertension) / Micturition / Cough / Change in posture (orthostatic) / Emotional stress
• Prodrome: Sweating / Nausea / Tunnel vision / Light-headedness
• Loss of consciousness: Complete/incomplete; duration
• Convulsions / Tongue bite / Incontinence (exclude seizure)
• Recovery: Immediate (cardiac arrhythmia) vs. Gradual (vasovagal — residual fatigue)
• Frequency of episodes

Sudden cardiac death as first manifestation occurs in conditions like hypertrophic cardiomyopathy, prolonged QT syndrome, and severe CAD — a prior history of syncope on exertion is a red flag. (Harrison's, p. 1885)

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E. EDEMA

• Site: Pedal / Sacral / Ascites / Anasarca
• Onset and progression: Bilateral dependent edema → central edema (gravity-dependent)
• Pitting / Non-pitting
• Diurnal variation: Worse in evening (cardiac) vs. constant (renal)
• Associated symptoms: Dyspnea / Orthopnea / Abdominal distension / Decreased urine output / Facial puffiness (renal/hepatic)

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F. FATIGUE / EXERCISE INTOLERANCE

• Duration
• Quantify: Activities now versus previously (stairs, walking distance)
• Associated with dyspnea or chest pain?

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G. COUGH / HEMOPTYSIS

• Dry / Productive
• Pink frothy sputum (acute pulmonary edema)
• Hemoptysis (mitral stenosis, pulmonary hypertension, PE)
• Nocturnal cough (can be an anginal equivalent or heart failure symptom)

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H. OTHER CARDIOVASCULAR SYMPTOMS

• Hoarseness (Ortner's syndrome — compression of left recurrent laryngeal nerve by large left atrium/pulmonary artery in mitral stenosis)
• Abdominal distension (ascites, hepatic congestion in right heart failure)
• Cold / Cyanotic extremities (peripheral arterial disease, low cardiac output)
• Claudication (intermittent — pain in calves/thighs on walking, relieved by rest; indicative of peripheral arterial disease)
• Headache, visual changes, epistaxis (hypertension)

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PART IV: PAST HISTORY

• Previous cardiac disease (MI, HF, valvular disease, arrhythmias)
• Rheumatic fever — sore throat episodes, joint pains (migratory polyarthritis), chorea, skin manifestations in childhood; establishes rheumatic valvular disease
• Hypertension — duration, treatment, control
• Diabetes mellitus
• Dyslipidemia
• Previous cardiac interventions: CABG / PCI / Valvulotomy / Valve replacement / Pacemaker / ICD
• Previous hospitalisations for cardiac events
• Tuberculosis (pericarditis, constrictive pericarditis)
• Thyroid disease (AF, heart failure)
• Anemia (high-output cardiac failure)
• Renal disease (hypertension, CKD-related cardiomyopathy)
• Surgeries (especially cardiac, vascular)

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PART V: DRUG HISTORY

• Current medications with doses and duration
• Cardiac medications: Antihypertensives / Antiplatelets (aspirin, clopidogrel) / Anticoagulants (warfarin — INR monitoring) / Statins / Diuretics / Digoxin / Beta-blockers / ACE inhibitors/ARBs / Nitrates / Antiarrhythmics
• Drug allergies (especially aspirin, antibiotics, contrast dyes)
• Cardiotoxic drugs: Anthracyclines (doxorubicin) / Trastuzumab / NSAIDs / Cocaine / Amphetamines / Clozapine
• OTC medications / Herbal preparations

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PART VI: PERSONAL HISTORY

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PART VII: FAMILY HISTORY

• Premature coronary artery disease (first-degree male relative <55 years, female <65 years)
• Hypertension
• Diabetes mellitus
• Dyslipidemia
• Sudden cardiac death / Cardiomyopathy (HOCM — autosomal dominant)
• Marfan syndrome (aortic dissection, aortic root dilation)
• Congenital heart disease
• Channelopathies (prolonged QT, Brugada syndrome)

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PART VIII: MENSTRUAL & OBSTETRIC HISTORY (females)

• Menstrual history (perimenopause — cardiovascular risk rises)
• Obstetric history: Gestational hypertension / Pre-eclampsia / Peripartum cardiomyopathy
• OCP use (thrombotic risk — PE, stroke)

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PART IX: SOCIOECONOMIC HISTORY

• Socioeconomic status (access to treatment, compliance)
• Insurance / Financial constraints
• Living conditions

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PART X: REVIEW OF SYSTEMS

• CNS: TIA / Stroke (thromboembolic — AF, valvular disease, carotid disease)
• Respiratory: Wheeze / PND / Cough
• GI: Nausea, anorexia (hepatic congestion, digoxin toxicity)
• Renal: Oliguria (low output cardiac failure), nocturia (early heart failure)
• Peripheral vascular: Claudication, rest pain, cold extremities, varicose veins, DVT / PE
• Thyroid: Heat/cold intolerance, weight change, tremor (hyper/hypothyroid → cardiac effects)
• Hematological: Anemia symptoms (high-output failure), bleeding (anticoagulation)

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PART XI: FUNCTIONAL STATUS SUMMARY

• Maximum exertion tolerated: _______________________________
• Symptoms limiting activity: ________________________________

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PART XII: PROVISIONAL DIAGNOSIS

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PART XIII: OUTLINE FOR PHYSICAL EXAMINATION (to follow history)

General Examination

• Build, nutrition, body habitus
• Pallor, Icterus, Cyanosis (central vs peripheral), Clubbing, Edema, Lymphadenopathy
• Jugular Venous Pressure & waveform (measured at sternal angle — abnormal if >4.5 cm at 30°); waveform analysis (prominent a wave, cannon a wave, v wave in TR)
• Pulse: Rate / Rhythm / Volume / Character / Vessel wall / Radio-radial/femoral delay
• Blood pressure: Both arms; postural drop
• Temperature, respiratory rate

Cardiovascular Examination

• Inspection of precordium: deformity, visible apex, pulsations, scars
• Palpation: Apex beat (character, displacement), thrills, parasternal heave
• Percussion: Cardiac dullness
• Auscultation: S1, S2, added sounds (S3, S4, opening snap, ejection click), murmurs (timing, site, character, radiation, grading)

Peripheral Signs of Specific Conditions

• Mitral stenosis: Malar flush, tapping apex
• Aortic regurgitation: Corrigan's pulse, de Musset's sign, pistol shot sounds, Traube's sign
• Right heart failure: Raised JVP, hepatomegaly (pulsatile in TR), ascites, peripheral edema
• Infective endocarditis: Splinter hemorrhages, Osler's nodes, Janeway lesions, Roth spots, splenomegaly

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KEY QUICK-REFERENCE TABLE — CARDIAC SYMPTOMS AND THEIR DIFFERENTIALS

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CVS CASE SHEET — DETAILED HISTORY TAKING FOR MEDICINE POSTINGS

---

PART I: PATIENT IDENTIFICATION

---

PART II: CHIEF COMPLAINTS

1. _____________________________ — since ___
2. _____________________________ — since ___
3. _____________________________ — since ___

---

PART III: HISTORY OF PRESENTING ILLNESS (HOPI)

---

A. CHEST PAIN / DISCOMFORT

• Onset: Sudden / Gradual
• Duration: Minutes / Hours / Continuous
• Character: Pressure / Squeezing / Burning / Tearing / Stabbing / Dull ache / Heaviness
• Site: Retrosternal / Precordial / Left-sided / Back / Epigastric
• Radiation: Neck / Left shoulder / Left arm / Both arms / Jaw / Back / Abdomen
• Severity: 0–10 scale
• Precipitating factors: Exertion / Emotion / Cold / Meals / Rest
• Relieving factors: Rest / Sublingual nitrates (response time) / Antacids / Posture
• Aggravating factors: Deep inspiration (pleuritic) / Palpation (musculoskeletal) / Swallowing (esophageal)
• Associated symptoms: Sweating / Nausea / Vomiting / Dyspnea / Syncope / Palpitations / Fever

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B. DYSPNEA

• Onset and duration
• Quantify exercise tolerance: Stairs / flat distance / ADLs
• NYHA Functional Classification:

• Type:
  • Exertional dyspnea — onset with activity, relieved by rest
  • Orthopnea — dyspnea on lying flat; number of pillows; onset after lying down (minutes)
  • Paroxysmal Nocturnal Dyspnea (PND) — wakes from sleep breathless; time to relief after sitting/standing up
  • Cardiac asthma — wheeze due to pulmonary congestion (must distinguish from bronchial asthma)
  • Dyspnea at rest — severe decompensation

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C. PALPITATIONS

• Onset: Sudden / Gradual
• Offset: Sudden / Gradual
• Character: Fast / Slow / Regular / Irregular / Missed beats / Forceful / Fluttering / Racing
• Duration of each episode
• Frequency and pattern
• Precipitating factors: Exertion / Caffeine / Alcohol / Stress / Medications / Thyroid symptoms
• Associated symptoms: Presyncope / Syncope / Chest pain / Dyspnea / Polyuria (post-SVT)
• Termination: Spontaneous / Valsalva manoeuvre / Carotid sinus massage / Required hospital treatment

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D. SYNCOPE / PRESYNCOPE

• Onset: Sudden (cardiac arrhythmia) vs. with prodrome (vasovagal)
• Posture at the time
• Precipitating factors:
  • Exertion → aortic stenosis, HOCM, pulmonary hypertension
  • Postural change → orthostatic hypotension
  • Micturition / Cough / Valsalva → situational syncope
  • Emotional stress → vasovagal
• Prodrome: Light-headedness / Sweating / Nausea / Tunnel vision / Tinnitus
• Loss of consciousness: Complete / Incomplete; duration
• Associated features during episode: Convulsions / Tongue bite / Incontinence / Pallor / Cyanosis
• Recovery: Immediate (arrhythmic) vs. Gradual with fatigue (vasovagal)
• Frequency of episodes
• Injuries sustained

Exertional syncope is a red flag — first presentation of HCM or severe AS can be sudden cardiac death.

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E. EDEMA

• Site: Pedal / Ankle / Pretibial / Sacral / Facial / Ascites / Anasarca
• Onset and progression: Unilateral or bilateral; ascending pattern
• Pitting: Yes / No; degree (1+ to 4+)
• Diurnal variation: Worse in evening, better in morning (cardiac) vs. constant (renal)
• Associated: Dyspnea / Orthopnea / Abdominal distension / Decreased urine output / Facial puffiness
• Precipitating / aggravating events: Dietary salt excess / Medication non-compliance / Intercurrent illness

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F. FATIGUE / EXERCISE INTOLERANCE

• Duration and progression
• Activities now vs. previously (quantify: stairs, walking distance)
• Associated with dyspnea or chest pain?
• Morning vs. evening predominance

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G. COUGH / HEMOPTYSIS

• Dry / Productive; if productive — colour, blood-staining
• Pink frothy sputum → acute pulmonary edema
• Hemoptysis → mitral stenosis (pulmonary venous hypertension), pulmonary embolism, pulmonary hypertension
• Nocturnal cough (anginal equivalent / early heart failure)
• Cough worsened by ACE inhibitors (if on treatment)

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H. OTHER CARDIAC SYMPTOMS

• Hoarseness — Ortner's syndrome (enlarged LA or pulmonary artery compressing left recurrent laryngeal nerve — classic in mitral stenosis)
• Abdominal distension — ascites, hepatomegaly (right heart failure / constrictive pericarditis)
• Claudication — pain in calves/thighs on walking, relieved by rest (peripheral arterial disease)
• Cold / cyanotic extremities — low cardiac output, peripheral arterial disease
• Headache, visual disturbances, epistaxis — hypertension
• Fever / chills — infective endocarditis, pericarditis, rheumatic carditis
• Weight loss — cardiac cachexia (advanced heart failure), infective endocarditis
• Nocturia — early heart failure (nocturnal redistribution of fluid)

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PART IV: PAST HISTORY

• Previous cardiac disease: MI / Heart failure / Valvular disease / Arrhythmia / Congenital heart disease
• Rheumatic fever: Episodes of sore throat, migratory polyarthritis, chorea, subcutaneous nodules, erythema marginatum in childhood — establishes rheumatic aetiology of valvular disease
• Hypertension: Duration, treatment, level of control, complications
• Diabetes mellitus: Duration, type, treatment — silent ischemia, autonomic neuropathy
• Dyslipidemia: Known levels, treatment
• Previous cardiac procedures: CABG / PCI / Valvuloplasty / Valve replacement / Pacemaker / ICD implantation / Ablation
• Previous hospitalisations for cardiac events
• Tuberculosis — pericarditis, constrictive pericarditis
• Thyroid disease — hyperthyroidism (AF, high-output failure); hypothyroidism (pericardial effusion, dyslipidemia)
• Anemia — high-output cardiac failure
• Renal disease — hypertension, CKD-related cardiomyopathy, fluid overload
• Connective tissue disease — SLE (Libman-Sacks endocarditis), scleroderma (pulmonary HTN), rheumatoid arthritis (pericarditis)
• Radiation therapy to chest — pericarditis, accelerated CAD, valvular disease

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PART V: DRUG HISTORY

• Current medications with doses and duration
• Cardiac drugs: Beta-blockers / ACE inhibitors / ARBs / Diuretics / Digoxin / Antiarrhythmics / Nitrates / Antiplatelet agents / Anticoagulants (warfarin — INR monitoring) / Statins
• Drug allergies: Aspirin / Antibiotics / Contrast agents / Iodine
• Cardiotoxic drugs: Anthracyclines (doxorubicin) / Trastuzumab / NSAIDs (fluid retention, worsens HF) / Cocaine / Amphetamines / Clozapine
• Drugs causing arrhythmia: QT-prolonging agents (antipsychotics, azithromycin, methadone)
• OTC medications / Herbal preparations
• Compliance with current medications

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PART VI: PERSONAL HISTORY

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PART VII: FAMILY HISTORY

• Premature CAD: First-degree male relative <55 years, female <65 years
• Hypertension
• Diabetes mellitus
• Dyslipidemia
• Sudden cardiac death — arrhythmia syndromes (long QT, Brugada, ARVC)
• Hypertrophic cardiomyopathy — autosomal dominant; family history of unexplained sudden death
• Marfan syndrome — aortic root dilation, dissection
• Dilated cardiomyopathy — familial forms
• Congenital heart disease (Down syndrome, Turner syndrome associations)
• Channelopathies

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PART VIII: MENSTRUAL & OBSTETRIC HISTORY (females)

• Menstrual history — irregular cycles, current menopausal status (post-menopause → rising cardiovascular risk)
• Obstetric history:
  • Gestational hypertension / Pre-eclampsia (future HTN and CAD risk)
  • Peripartum cardiomyopathy
  • Number of pregnancies — significant mitral stenosis may first present in pregnancy (increased cardiac output)
• Oral contraceptive use — thrombotic risk (PE, stroke, MI especially in smokers)

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PART IX: SOCIOECONOMIC HISTORY

• Socioeconomic status
• Dietary patterns related to income
• Access to healthcare and medications
• Drug compliance in context of affordability
• Occupation and physical demands
• Living conditions (crowded → rheumatic fever risk)

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PART X: REVIEW OF SYSTEMS

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PART XI: FUNCTIONAL STATUS SUMMARY

• Maximum exertion tolerated: ___________________________
• Symptoms limiting activity: ___________________________
• CCS Angina Class (if chest pain present): ___

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PART XII: PROVISIONAL DIAGNOSIS FRAMEWORK

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PART XIII: OUTLINE FOR PHYSICAL EXAMINATION (follows history)

General Examination

• Built / nutrition / body habitus (cachexia, Marfanoid)
• Pallor (anemia → high output failure)
• Icterus (right heart failure → hepatic congestion)
• Cyanosis: Central (cardiac shunt, pulmonary HTN) vs. Peripheral (low output)
• Clubbing: Grades I–IV; causes — cyanotic CHD, infective endocarditis
• Edema: Bilateral pitting pedal — grade and distribution
• Lymphadenopathy
• JVP: Measured from sternal angle — abnormal if >4.5 cm at 30°; waveform analysis
  • Prominent a wave → reduced RV compliance (pulmonary HTN, PS)
  • Cannon a wave → AV dissociation (VT, complete heart block)
  • Absent a wave → atrial fibrillation
  • Large v wave → tricuspid regurgitation
• Pulse: Rate / Rhythm / Volume / Character (collapsing, plateau, bisferiens, alternans) / Vessel wall / Radio-radial and radio-femoral delay
• Blood pressure: Both arms; postural measurements

Cardiovascular Examination

• Inspection: Precordial deformity, visible apex, visible pulsations, scars (sternotomy, lateral thoracotomy), pacemaker bulge
• Palpation: Apex beat (site, character — tapping, heaving, thrusting, dyskinetic); thrills (systolic/diastolic); left / right parasternal heave; palpable P2
• Percussion: Left and right borders of cardiac dullness
• Auscultation:
  • Heart sounds: S1 (mitral + tricuspid closure), S2 (A2 + P2 — splitting, intensity); S3 (volume overload / HF); S4 (reduced compliance / hypertrophy)
  • Added sounds: Opening snap (MS), ejection click (AS, PS, bicuspid AV), mid-systolic click (MVP), pericardial rub, pericardial knock
  • Murmurs: Timing / Site of maximum intensity / Character / Radiation / Grading (Levine 1–6) / Effect of respiration (right-sided louder on inspiration — Carvallo's sign)

Peripheral Cardiovascular Signs by Condition

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QUICK REFERENCE — SYMPTOM TO DIAGNOSIS SUMMARY

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