Specifics of questioning in arterial blood pressure changes
When interviewing a cardiac patient with suspected arterial hypertension, it is important to consider their awareness. Patients with a long-standing history of the disease usually know their usual blood pressure (BP) figures. Key questions during history-taking should address two aspects.
First, it is necessary to determine peak values — what maximum pressure figures have ever been recorded in the patient. Second, subjective tolerance is assessed: whether the BP elevation is asymptomatic or accompanied by unpleasant sensations (e.g., nausea, headache, and other concomitant complaints).
Special attention is paid to the medication history. The physician must clarify the complete list of medications taken to lower BP, assess the regularity of their intake, the achieved effect, and the tolerability of therapy (presence of side effects).
Structure of the medical history and anamnesis vitae
After clarifying the main complaints, the physician proceeds to structure the medical history. The history-taking algorithm includes a clear chronology of disease development: it is necessary to record the exact time of the appearance of the first symptoms. Next, the effectiveness of all previously administered therapy is evaluated.
An important social and medical criterion is the patient's working capacity. The physician records the frequency and duration of periods of disability, as well as the presence of disability status associated with undergoing medical and social expertise. Hospitalizations must be accounted for: their frequency and causes (especially related to angina pectoris or decompensation of hypertensive disease).
When taking the anamnesis vitae (Anamnesis vitae), baseline parameters are recorded: lifestyle, working and living conditions, past illnesses, bad habits, and heredity. For women, taking a gynecological history is mandatory (use of oral contraceptives, menstrual cycle disorders), as perimenopause and the onset of menopause are critical periods for the development of cardiac pathology.
Working with medical data and psychosomatics
The analysis of medical documentation requires strict verification of data. It is necessary to thoroughly study the results of previous examinations (including ECG and EchoCG) and medical opinions. Diagnoses stated by the patient themselves (e.g., "previous myocardial infarction" or "valvular heart disease") must be treated with critical caution. Patients often use these terms incorrectly to denote any heart problems.
During a clarifying conversation about the circumstances of hospitalization, it is important to compare the formal reason for admission with how the patient views the situation themselves — this helps formulate a list of questions for differential diagnosis.
Detailing pharmacotherapy implies not just a list of drugs, but an exact indication of dosages, duration of intake, and signs of intolerance. One should not forget about the psychosomatic component. Assessing the attitude towards the disease and its impact on quality of life is extremely important, as the treatment of certain conditions (e.g., extrasystole) directly depends on their subjective tolerance by the patient. The potential psychogenic nature of symptoms in the pathogenesis is also taken into account.
Assessment of CHD risk factors and interview cyclicality
The history-taking process is non-linear. For example, upon confirming angina pectoris or a myocardial infarction in the past, the physician demonstrates cyclicality: returns to details, clarifies the nature of nutrition, and conducts a conversation about the need to replace animal fats with vegetable fats. The emphasis in assessing risk factors is traditionally placed on coronary heart disease.
When studying heredity, it is important to find out what close relatives fell ill with and at what age they died. A red flag is the death of a parent from myocardial infarction under the age of 50.
Information about bad habits is carefully gathered: smoking intensity is assessed and a strict "alcohol history" is taken. If a patient with signs of cardiac damage has progressing heart failure (HF), their statements about completely quitting alcohol should be treated with justified doubt.
Briefly: answers to topical questions
What characteristics of the pain syndrome need to be ascertained when suspected of an angina attack?
To confirm or exclude angina pectoris, several key pain parameters need to be ascertained. These include:
- Localization — pain strictly behind the sternum (retrosternal).
- Character — squeezing, pressing, a feeling of heaviness or tightness (burning); aching and stabbing pains are atypical.
- Radiation — usually to the left arm, left shoulder, sometimes to the right shoulder, back, epigastrium, lower jaw.
- Relation to exertion (triggers) — occurs at the peak of physical activity, during emotional stress, in the cold, after a heavy meal.
- Duration — short-term, usually from 1–3 to 15 minutes.
- Relief of the attack — the pain quickly disappears after cessation of exertion or sublingual administration of nitroglycerin.
What modifiable CHD risk factors need to be identified during the anamnesis vitae?
When taking the anamnesis, it is necessary to identify CHD risk factors that are amenable to assessment and correction. Among them, the following should be assessed:
- Obesity (including the state of subcutaneous adipose tissue).
- Arterial hypertension.
- Diabetes mellitus.
- Hyperlipidemia / dyslipidemia.
- Smoking — with an assessment of intensity.
How to differentiate cardiac and pulmonary dyspnea during history-taking?
Differentiating dyspnea during history-taking is aided by assessing its relation to physical exertion and body position. Dyspnea of cardiac origin (Dyspnea) is characterized by:
- Decreased exercise tolerance — first occurs during physical activity, then with lesser efforts and at rest.
- Orthopnea (Orthopnea) — dyspnea in the horizontal position, alleviated in a sitting position or with a high headrest.
- Paroxysmal nocturnal dyspnea — attacks of suffocation at night (cardiac asthma).
When pulmonary pathology (acute nature) is suspected, dyspnea may occur suddenly (bronchial asthma attack, pneumothorax).
For express assessment of hypertension, remember the "3P" rule: Peak BP figures, Portability/Tolerance (symptoms), Pills/Preparations (doses, effect, and side effects).
Class and exam questions
How should one treat diagnoses stated by the patient themselves?
With extreme caution. Patients may call any chest pain a "heart attack" or incorrectly use the term "valvular heart disease". Verification using discharge summaries, ECG, and EchoCG results is required.
What does the cyclicality of history-taking consist of?
It is a non-linear interview process. Upon learning a new fact (e.g., the presence of a history of myocardial infarction), the physician must go back to detail the nature of nutrition and other concomitant factors.
What is important to ask women when taking the anamnesis vitae?
It is necessary to clarify the gynecological status: the presence of menstrual cycle disorders, the use of oral contraceptives, as well as the onset of menopause or perimenopause.
Why is the assessment of the psychosomatic component important in extrasystole?
The treatment tactics for extrasystole largely depend on how severely the patient subjectively tolerates these rhythm disturbances and how they affect their quality of life.
What else to study on this topic
- Features of differential diagnosis based on the patient's perspective of the situation.
- Specifics of taking an "alcohol history" in patients with progressive heart failure.
- The impact of the psychogenic nature of symptoms on the pathogenesis of cardiovascular diseases.
- Rules for assessing the effectiveness and tolerability of antihypertensive therapy.
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