• Name:
• Age/Sex:
• Education:
• Address:
• Occupation:
⸻
Chief Complaints
Mention Chief complaints in chronological order with duration.
⸻
History of Presenting Illness (HOPI)
Chest Pain
• Present / Absent
• Duration:_____
• Onset: Sudden / Gradual
• Course: Progressive / Non-progressive
• Site: Central / Retrosternal / Left-sided / Precordial / Other:____
• Character: Dull aching / Heaviness / Tightness / Crushing / Stabbing / Burning / Other:____
• Radiation: Left shoulder / Left arm / Jaw / Neck / Back / Epigastrium / Non-radiating
• Aggravating factors: Exertion / Emotional stress / Deep inspiration / Coughing / Meals / Lying down
• Relieving factors: Rest / Sublingual nitrates / Sitting forward / Analgesics
• Associated symptoms: Sweating / Breathlessness / Palpitations / Nausea / Vomiting / Dizziness / Syncope
⸻
Breathlessness (Dyspnea)
• Present / Absent
• Duration: ___
• Onset: Sudden / Gradual
• Course: Progressive / Non-progressive
• Pattern: Continuous / Intermittent
• Occurs: On exertion / At rest
• Aggravating factors: Physical activity / Lying flat
• Relieving factors: Rest / Sitting upright
Associated Features
• Orthopnea: Present / Absent
- Number of pillows: ______
• Paroxysmal nocturnal dyspnea (PND): Present / Absent
• Nocturnal cough: Present / Absent
• Reduced exercise tolerance: Present / Absent
⸻
Palpitations
• Present / Absent
• Duration:___
• Onset: Sudden / Gradual
• Rhythm: Regular / Irregular
• Pattern: Episodic / Persistent
• Duration of episodes:___
• Associated Symptoms: Chest pain / Breathlessness / Dizziness / Syncope / Anxiety / Sweating
• Precipitating Factors: Exertion / Caffeine intake/ Stress / Alcohol / Spontaneous occurrence
⸻
Pedal Edema
• Present / Absent
• Duration:____
• Laterality: Bilateral / Unilateral
• Onset: Sudden / Gradual
• Course: Progressive / Non-progressive
• Extent: Ankles / Legs / Thighs
• Associated Symptoms: Abdominal distension / Reduced urine output / Breathlessness / Weight gain.
⸻
Syncope
• Present / Absent
• Number of episodes:__
• Onset: Sudden / Gradual
• Duration:___
• Circumstances: During exertion / Associated with palpitations / Associated with chest pain / Postural change
• Recovery: Spontaneous / Delayed
⸻
Fatigue
• Present / Absent
• Easy fatigability: Present / Absent
• Reduced exercise tolerance: Present / Absent
• Interference with daily activities: Present / Absent
⸻
Cyanosis
• Present / Absent
• Site: Lips / Tongue/ Fingers / Toes
• Since: Birth / Acquired later in life
• Associated Features: Breathlessness / Clubbing
⸻
Constitutional Symptoms
• Fever: Present / Absent
• Loss of appetite: Present / Absent
• Weight loss: Present / Absent
• Fatigue: Present / Absent
• Malaise: Present / Absent
• Night sweats: Present / Absent
Suggestive of: Infective endocarditis, Chronic heart failure.
⸻
Past History
History / No history of:
• Hypertension
• Diabetes mellitus
• Dyslipidemia
• Rheumatic fever
• Rheumatic heart disease
• Ischemic heart disease
• Myocardial infarction
• Heart failure
• Congenital heart disease
• Stroke/TIA
• Chronic kidney disease
Previous Interventions/Hospitalizations
• Previous admissions: Yes / No
•ICU admission: Yes / No
• Angioplasty (PCI): Yes / No
• CABG: Yes / No
• Valve surgery/replacement: Yes / No
• Pacemaker implantation: Yes / No
• Blood transfusion: Yes / No
⸻
Drug History
History of use of:
• Antihypertensives
• Antiplatelets
• Anticoagulants
• Statins
• Diuretics
• Beta-blockers
• ACE inhibitors/ARBs
• Digoxin
• Nitrates
• Other medications:
• Drug allergy: Present / Absent
⸻
Treatment History
Previous investigations:
• Electrocardiography (ECG)
• Echocardiography (2D Echo)
• Coronary angiography
• Treadmill test (TMT)
• CT Coronary angiography
• Holter monitoring
• Other: _______
Previous diagnosis: ___
Treatment received:___
• Medical management
• ICU admission
• PCI
• CABG
• Valve replacement
• Pacemaker implantation
• Other:____
⸻
Personal History
• Appetite: Normal / Reduced
• Diet: Vegetarian / Mixed
• Sleep: Adequate / Disturbed
- Disturbance due to: Orthopnea / PND
• Bowel habits: Normal / Abnormal
• Bladder habits: Normal / Abnormal
⸻
Addiction History
Smoking
• Duration: ____
• Number of cigarettes/bidis per day: ____
• Present / Absent
• Type:___
Tobacco/Substance Abuse
• Present / Absent
• Details:___
Family History
History of:
• Hypertension
• Diabetes mellitus
• Ischemic heart disease
• Sudden cardiac death
• Cardiomyopathy
• Congenital heart disease
• Dyslipidemia
• Family pedigree suggestive of inherited cardiac disease: Yes / No
⸻
History Suggestive of Ischemic Heart Disease
• Exertional retrosternal chest pain
• Radiation to left arm/jaw
• Relief with rest or nitrates
• Associated sweating
• Diabetes mellitus
• Hypertension
• Dyslipidemia
• Smoking
• Previous MI/PCI/CABG
⸻
History Suggestive of Heart Failure
• Progressive breathlessness
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Pedal edema
• Easy fatigability
• Reduced exercise tolerance
• Nocturnal cough
• Weight gain
⸻
History Suggestive of Rheumatic Heart Disease
• Childhood sore throat
• Rheumatic fever
• Exertional dyspnea
• Palpitations
• Orthopnea
• Hemoptysis
⸻
History Suggestive of Infective Endocarditis
• Prolonged fever
• Weight loss
• Fatigue
• Previous valvular heart disease
• Prosthetic valve
• Intravenous drug abuse
• Recent dental procedures
⸻
Once history taking is complete, proceed to CVS Examination.
⸻
Mr./Ms. ______, a ___-year-old Male/Female, resident of ______ and working as a ______, presented with complaints of __________ for the past _____ days/months/years.
The patient was apparently asymptomatic until _____ ago when he/she developed chest pain, which was sudden/gradual in onset and progressive/non-progressive in nature. The pain was central/left-sided/retrosternal/precordial, dull aching/heaviness/tightness/crushing/stabbing/burning in character, radiating to the left shoulder, left arm, jaw, neck, back, or epigastrium, or was non-radiating.
It was aggravated by exertion, emotional stress, deep inspiration, coughing, meals, or lying down and relieved by rest, sublingual nitrates, sitting forward, or analgesics. The pain was associated with sweating, breathlessness, palpitations, nausea, vomiting, dizziness, or syncope.
- Retrosternal heaviness radiating to left arm/jaw → Stable angina, Acute coronary syndrome
- Pain lasting >20 minutes with sweating → Myocardial infarction
- Sharp pleuritic pain relieved by sitting forward → Acute pericarditis
- Sudden tearing pain radiating to back → Aortic dissection
- Sharp pain aggravated by inspiration → Pulmonary embolism, pleurisy
The patient developed breathlessness since ______. It was sudden/gradual in onset, progressive/non-progressive, continuous/intermittent, occurring on exertion or at rest. It was aggravated by physical activity or lying flat and relieved by rest or sitting upright.
Severity was assessed according to the New York Heart Association (NYHA) Functional Classification:
The patient did/did not complain of orthopnea (requiring ___ pillows) or paroxysmal nocturnal dyspnea (PND).
- Progressive exertional dyspnea → Heart failure, valvular heart disease
- Orthopnea & PND → Left ventricular failure
- Sudden severe dyspnea → Acute pulmonary edema
The patient experienced/did not experience palpitations since _____. They were sudden/gradual in onset, regular/irregular, episodic/persistent, lasting ______ minutes/hours. Palpitations were associated with chest pain, dizziness, syncope, breathlessness, anxiety, or sweating. They were precipitated by exertion, caffeine, stress, alcohol, or occurred spontaneously.
- Sudden onset and termination → Supraventricular tachycardia
- Irregularly irregular palpitations → Atrial fibrillation
- Palpitations with syncope → Serious arrhythmia
The patient developed swelling of feet since _____. It was bilateral/unilateral, gradual/sudden in onset, progressive/non-progressive, extending up to ankles/legs/thighs. It was associated with abdominal distension, reduced urine output, breathlessness, or weight gain.
- Bilateral pitting edema → Congestive heart failure
- Edema with ascites → Right heart failure
- Unilateral edema → Deep vein thrombosis
The patient did/did not experience episodes of loss of consciousness. If present, the episode was sudden, brief, associated with exertion, palpitations, chest pain, or postural change, with spontaneous recovery.
- Cardiac arrhythmia
- Aortic stenosis
- Hypertrophic cardiomyopathy
- Vasovagal syncope
The patient complained/did not complain of easy fatigability or reduced exercise tolerance, interfering with routine daily activities.
- Chronic heart failure
- Cardiomyopathy
- Severe valvular heart disease
- Anemia
The patient developed/did not develop bluish discoloration of lips, tongue, fingers, or toes. It was present since birth/acquired later in life and associated with breathlessness or clubbing.
- Cyanotic congenital heart disease
- Eisenmenger syndrome
- Advanced heart failure
History/ No history of Loss of appetite, weight loss, fever, fatigue, malaise, and night sweats
- Prolonged fever with weight loss → Infective endocarditis
- Fatigue with dyspnea → Chronic heart failure
- Night sweats → Infective endocarditis
- Exertional retrosternal chest pain
- Radiation to left arm/jaw
- Relief with rest or nitrates
- Associated sweating
- Diabetes
- Hypertension
- Dyslipidemia
- Smoking
- Previous MI/PCI/CABG
- Progressive breathlessness
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pedal edema
- Easy fatigability
- Reduced exercise tolerance
- Nocturnal cough
- Weight gain
- Childhood sore throat
- Rheumatic fever
- Exertional dyspnea
- Palpitations
- Orthopnea
- Hemoptysis
- Prolonged fever
- Weight loss
- Fatigue
- Previous valvular heart disease
- Prosthetic valve
- Intravenous drug abuse
- Dental procedures
Past History: History of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, ischemic heart disease, myocardial infarction, heart failure, congenital heart disease, stroke, or chronic kidney disease — present/absent. Previous hospital admissions, angioplasty, CABG, valve surgery, pacemaker implantation, or blood transfusion.
Drug History:History/ No History of use of antihypertensives, antiplatelets, anticoagulants, statins, diuretics, beta-blockers, ACE inhibitors/ARBs, digoxin, or nitrates. No history of any drug allergy.
Treatment History: Previous ECG, echocardiography, coronary angiography, TMT, CT coronary angiography, Holter monitoring. Previous diagnosis, treatment, hospitalizations, ICU admission, PCI, CABG, valve replacement, or pacemaker implantation.
Personal History:His/her Appetite is normal/reduced. He/ she is Vegetarian/ consumes mixed diet. His/Her Sleep is adequate/disturbed due to orthopnea or PND. Bowel and bladder habits are normal. Smoking: non-smoker/ex-smoker/current smoker : pack years ____. Alcohol: present/absent — type, quantity, duration. Tobacco chewing or substance abuse — present/absent.
Family History:No family history of Hypertension, diabetes, ischemic heart disease, sudden cardiac death, cardiomyopathy, congenital heart disease, or dyslipidemia
Mr./Ms. ______, a __-year-old individual, presented with mild atypical chest discomfort for ___ days without exertional chest pain, breathlessness, palpitations, syncope, pedal edema, hypertension, diabetes, smoking, or significant family history, suggestive of a non-cardiac cause of chest pain.
Mr./Ms. ______, a __-year-old diabetic/hypertensive smoker, presented with exertional retrosternal chest heaviness radiating to the left shoulder and arm, relieved by rest and nitrates, suggestive of chronic stable angina.
Mr./Ms. ______, a __-year-old individual with multiple cardiovascular risk factors, presented with severe prolonged retrosternal crushing chest pain radiating to the left arm and jaw, associated with sweating, nausea, vomiting, and breathlessness, suggestive of acute myocardial infarction.
Mr./Ms. ______, a __-year-old hypertensive patient, presented with progressively worsening exertional breathlessness, orthopnea, paroxysmal nocturnal dyspnea, bilateral pedal edema, easy fatigability, and reduced exercise tolerance, suggestive of congestive cardiac failure.
Mr./Ms. ______, a __-year-old individual with a history of rheumatic fever, presented with progressive exertional dyspnea, orthopnea, palpitations, occasional hemoptysis, and easy fatigability, suggestive of rheumatic mitral stenosis.
Mr./Ms. ______, a __-year-old patient with pre-existing valvular heart disease/prosthetic valve, presented with prolonged fever, fatigue, weight loss, and progressive breathlessness, suggestive of infective endocarditis.
Mr./Ms. ______, a __-year-old individual, presented with recurrent episodes of sudden-onset palpitations associated with dizziness/syncope and occasional breathlessness, suggestive of a cardiac arrhythmia.
