Presenting Complaint - Core presentations
There are many potential differential causes for chest pain so it is essential to take a thorough history of the symptoms using SOCRATES
- Site - Where?
- Onset – When? Sudden or gradual?
- Character - What is the pain like?
- Radiation – Where to?
- Associations - Any other signs or symptoms?
- Time course - Any pattern?
- Exacerbating/Relieving factors - Anything change the pain?
- Severity - How bad?
Do you ever become aware of your own heartbeat? Again explore SOCRATES to determine the nature of the palpitations. It is important to ask about the character of the palpitations focussing on the rate and rhythm as this could be evidence of arrhythmias.
- Dyspnoea is the subjective sensation of SOB
- Tachypnoea is the objective evidence of SOB (increased respiratory rate)
- Orthopnoea is breathlessness when lying flat
- How many pillows do you use?
- Paroxysmal nocturnal dyspnoea
- Waking at night gasping for breath
There are many potential causes so there are several key points to establish in order to differentiate issues
- All the time
- Woken from sleep
- During exertion
- Relieving factors
- Exacerbating factors
- Associated symptoms
- Chest pain, palpitations
- Cough, wheeze, sputum, haemoptysis
- Ankle oedema
- Assess normal exercise tolerance
- Smoking/social history
- Cardiac causes
- Heart Failure
- Valve disease
- Myocardial Ischaemia
- Pericardial disease
- Non cardiac causes
- Pulmonary disease
- Anaemia, obesity or being unfit
Fainting, dizzyness or loss of consciousness can be associated with several conditions so it is important to determine if the syncope is cardiac in origin.
- How long did it last?
- Short duration suggests cardiac while longer durations suggest neurological
- Was there any other symptoms?
- Was it sudden or gradual in onset?
- Was there any warning or precipitating factors?
Past medical history
- Identify key cardiac risk factors early
- Previous MI/angina
- Previous investigations ECGs/Echocardiograms
- Procedures such as stents/bypass ops
- Corneal arcus, xanthelasma, xanthoma
- Diabetes mellitus
- Peripheral vascular disease
- Cerebrovascular disease (strokes)
Family history – cardiac
- Heart attack in 1st degree male relative (father/brother/son) <55
- Heart attack in 1st degree female relative (mother/sister/daughter) < 65
Note any cardiac medication such as beta blockers, ACE inhibitors, GTN, digoxin, statins (for cholesterol)
Confirm impact of symptoms on daily life. For example do they struggle to get up stairs with their angina pains?