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34 Cards in this Set
- Front
- Back
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The Art of Taking a History
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A history is the documentation of the past events and subjective findings, including symptoms, and a patient’s current state of health ◦Documenting the presence or the progression of signs and symptoms is important in determining: ◾The degree of HF ◾Whether treatment or medical interventions are therapeutic and achieving the desired goal for each patient •Many patients may not associate specific sign/symptoms with HF, so it is important to ask specific questions in order to obtain the information needed to develop the plan of care |
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Use a systematic method
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In order to obtain an accurate history, If a patient acknowledges a specific symptom, ask the following questions, using the mnemonic “PQRST” to gain more specific details:
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P = Provocation and Palliation
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What causes the symptom? What makes it worse? What makes it better? |
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Q = Quality and Quantity
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How does it feel, look or sound? ◦Let patient describe the pain in their own words, sometimes patients say what they think you would like to hear •What is the quality of the pain? Is it: ◦Sharp? ◦Dull? ◦Stabbing? ◦Burning? ◦Crushing? •If describing a discharge: ◦Thick? ◦Runny? ◦Clear? ◦What color? •If describing a psychological problem ◦Do the voices drown out other sounds? ◦Whose voice does it sound like? |
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R = Region and Radiation
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R = Region and Radiation
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Where is it? •Does it spread? •Where does the pain radiate? •Is it in one place? •Does it go anywhere else? •Did it start elsewhere and is now localized to one spot? •In the case of pain, does it travel: ◦Down your back? ◦Down your arms? ◦Up your neck? ◦Down your legs? |
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S = Severity and Scale
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S = Severity and Scale
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Does it interfere with activities? •How does it rate on a scale of 1 to 10? •How bad is it when it's at its worst? •Does it force you to sit down, lie down, slow down? •How long does an episode last? |
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T = Timing and Type of Onset
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When did it begin? •How often does it occur? •Is the onset sudden or gradual? •How long does it last? •When was the first date it happened? •What were you doing when you first experienced or noticed it? •How often do you experience it: hourly? daily? weekly? monthly? •When do you usually experience it: daytime? night? in the early morning? •Are you ever awakened by it? Does it lead to anything else? •Is it accompanied by other signs and symptoms? •Does it ever occur before, during or after meals?•Does it occur seasonally? |
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How Does the History Help?
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Documenting the presence or the progression of signs and symptoms is important in determining: ◦The degree of HF ◦Whether treatment or medical interventions are therapeutic and achieving the desired goal for the patient |
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Elements of a History Include
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Chief complaint •History of Present Illness (HPI) •Past Medical History •Family history •Social history and habits including past or present history ◦Drug/Blood transfusion history •Nutritional history •Review of Systems ◦OB/GYN history |
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Chief Complaint
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Reason for the visit in the patient’s own words •Put the reason in quotes |
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History of Present Illness (HPI)
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Concise description of the patient’s current health status focusing on current HF signs and symptoms ◦Each positive symptom should be explored with the patient using the “PQRST” mnemonic ◦Document current treatment modalities or plan of care including the patient’s stated adherence to the prescribed plan of care – medications, dietary and fluid restrictions ◦Document recent clinic visits, hospitalizations or emergency department visits for similar signs and symptoms, and any new prescriptions or change in prescriptions |
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Past Medical History
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History of cardiac-related conditions •History of non-cardiac conditions that may increase morbidity in HF •Allergies •Surgical history/procedures •Medications •Immunization history |
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Family and Social History
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Focus on direct family members having: ◦Coronary artery disease (CAD)◦Stroke or transient ischemic attack ◦Cardiomyopathies ◦Sudden death ◦Hypertension ◦Hyperlipidemia •Social history and habits including past or present history of: ◦Tobacco abuse (documented as pack/year history) ◦ETOH, recreational drug use ◦Current level of physical activity ◦Education level ◦Pets and travel history •Nutritional history including: ◦Weight loss or weight gain ◦Summary of average dietary intake focusing on fluid status and sodium intake |
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Review of Symptoms
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Since patients do not always recognize all of their symptoms as evolving from HF, each of the following categories should be explored with the patient using the “PQRST” mnemonic •Shortness of breath (SOB) - the most common heart failure symptom •Orthopnea can be very suggestive of HF •Paroxysmal nocturnal dyspnea (PND) •Dyspnea on exertion (DOE) •Cough •Wheezing •Symptoms •Chest pain or angina •Gastrointestinal Problems •Fluid Overload •Ascites•Palpitations •Mental status changes or cerebral hypoperfusion •Sleep disturbances •Skin alterations |
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Shortness of Breath (SOB)
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SOB or DOE may occur early in the disease process before other symptoms of HF are evident •As HF becomes progressively worse, less exertion is required before the patient develops a sense of dyspnea •Have patient’s normal activity level changed or been curtailed? |
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Orthopnea
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Occurs due to the redistribution of fluid from the lower extremities into the central circulation during recumbency •Results in increased pulmonary capillary pressure •Can occur rapidly with change in positioning and is usually relieved with sitting upright •Appropriate questions to ask: ◦Number of pillows used beneath the patient’s head while sleeping in order to breathe comfortably ◦Degree of elevation of the head of the bed ◦If the patient must sleep in a recliner in order to breathe comfortably |
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Paroxysmal Nocturnal Dyspnea (PND)
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Sudden onset of SOB that wakes a patient from sleep •PND is caused by fluid accumulation in the lungs entering the alveoli during sleep •During the day, the fluid is retained in the legs, but at night, while sleeping, the body reabsorbs this fluid resulting in an increase in total blood volume leading to pulmonary edema •Associated symptoms can include anxiety and a sense of suffocation •Appropriate questions to ask include not only what the patient does to relieve the symptom of PND, but also the frequency of episodes |
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Cough
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Can be due to pulmonary, cardiac, gastric causes or a side effect of medications •A dry hacking cough can be associated with angiotensin converting enzyme inhibitors (ACEI) as the result of increased bradykinin levels •Frequently overlooked symptom is a chronic non productive cough that is worse in the recumbent position. This is frequently associated with pulmonary congestion •Associated symptoms to explore when asking about a cough include presence of hemoptysis, wheezing, rhinorrhea, or sputum production |
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Wheezing
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May be caused by congestion of bronchial mucosa and compression of small bronchi •May be related to pulmonary disease •May be present at rest or with exertion |
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Fatigue
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Decreased exercise tolerance - compare what the patient can do now with what they have been able to do in the past •Comparison between what a patient could do in the past (3-6 months ago) compared to their present level of activity •Fatigue may occur due to a decreased cardiac reserve •As patient’s activity increases, the heart cannot maintain a cardiac output sufficient to sustain the activity •Leg fatigue/heaviness due to edematous extremities and poor peripheral blood flow may develop as the result of : ◦A low cardiac output ◦Venous congestion in the lower extremities ◦Neurohormonal suppression of vasodilatory responses |
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Chest Pain or Angina
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May be the result of a progression of HF with a subsequent reduced cardiac output •May be the associated with progression of CAD •May occur due to myocardial stretch in fluid volume overload •Important points to remember are: ◦Some will only use the term discomfort or pressure, not chest pain ◦Women may have an angina equivalent and complain of back pain, abdominal pain or neck pain ◦Because of neuropathy, diabetics may not experience chest pain or angina, but may have other symptoms such as shortness of breath |
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Gastrointestinal Problems
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May be due to ascites, gut edema, passive liver congestion with fluid retention ◦Abdominal discomfort or tenderness ◦Bloating ◦Episodes of nausea and vomiting •Early satiety •Change in bowel habits including constipation, due to fluid shifting from intravascular space into tissues •Anorexia or a loss of appetite •Dysgeusia (alteration in the sense of taste) may be caused by some medications such as ACE-I or angiotensin receptor blockers |
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Fluid Overload
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Edema is extravascular fluid sequestered in the body’s tissues, usually a symptom of right HF, either in combination with left HF or by itself •Generalized throughout the body, or for male patients, scrotal edema •Edema may also be related to medications such as calcium channel blockers or non-steroidal anti-inflammatory drugs (NSAIDs), increased sodium intake, or venous stasis |
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Ascites
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Extra fluid within the peritoneal cavity caused by high pressure in the hepatic veins and portal circulation •Symptoms may include: ◦Pants or clothes that feel tighter around the waist •Increase in weight one kilogram increase in weight (or 2.2 pounds), equals one liter of retained fluid |
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Palpitations
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The most common dysrhythmia with HF is atrial fibrillation (AF) •Patients may note fast irregular heartbeat and a fluttering sensation, or they may not feel any different when AF occurs •AF may be either chronic or paroxysmal •Palpitations may also be accompanied by symptoms of SOB, dizziness or near-syncope |
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Mental Status Changes
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Can occur as a result of hypoxia due to low cardiac output •Related to worsening HF manifested as: ◦Forgetfulness ◦Change in attention span (or inattentiveness) ◦Confusion, poor judgment, or uncoordinated movements •Mental status changes may also indicate that the patient has had a stroke or a transient ischemic attack •Document the etiology, timing and frequency of these events |
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Sleep Disturbances
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Nocturia may be causing a patient to awaken frequently to urinate and decrease deep-sleep intervals •Snoring may be indicative of sleep apnea, which may be a cause of HF or contribute to worsening HF. Important questions to ask include : ◦Does the patient feel well rested in the morning when awakening? ◦Do they nap often or fall asleep easily during the day? ◦Have they had a positive sleep study? ◦Do they have either CPAP or BiPAP and do they use it? •Daytime sleepiness may be associated with sleep apnea or frequent night-time awakenings as a result of nocturia, orthopnea, or PND •Insomnia may be related to stress, anxiety, depression, or if napping excessively during the day |
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Skin Alterations
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Skin alterations may be present because of ◦Poor peripheral perfusion due to low cardiac output ◦Venous stasis ◦Peripheral arterial disease •Peripheral edema ◦Development of deep vein thromboses (DVT) ◦Mottling usually seen in poor perfusion, includes blue or grayish coloring, particularly in the extremities and is typically accompanied by a prolonged capillary refill ◦Temperature changes may indicate poor perfusion◦Skin cool, cold, or clammy to the touch can indicate poor perfusion ◦Hot reddened skin can indicate a DVT which may be related to bed rest or limited mobility |
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1. When a patient acknowledges a symptom, use the mnemonic “PQRST to gain more specific details: The “S” stands for:Choose one: Symptom Severity Scale b and c |
b and c (severity & scale)
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2. The patient’s chief complaint is Choose one: The reason for their visit, in their own words The underlying diagnosis or problem that the patient is seeking help for The history of the present illness |
The reason for their visit, in their own words
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3. What is not a typical abdominal symptom of HF? Choose one: Early satiety Frequent belching Abdominal discomfort, bloating or tenderness Nausea/vomiting |
Frequent belching
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4. Symptoms such as forgetfulness, change in attention span (or inattentiveness), confusion, poor judgment, or uncoordinated movements may be the result of: Choose one: Hypoxia Worsening HF A stroke or TIA All of the above |
All of the above
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