MODULE 17: PART 8

Cardiology

History taking systems and symptoms

by Kate ODonovan
Part one of this article described the principles underpinning history taking in a person presenting with cardiovascular disease. The main principles of history taking include presenting complaint, past health history, family and personal history and review of the systems. The purpose of history taking is to ascertain what has caused the patient to seek healthcare assistance and is a precise chronological description of the patients current health status. It normally occurs in the form of patient-nurse interview format. This article (part 2) will focus on a review of the systems and common symptoms associated with cardiovascular disease Review of the systems According to Woods1 a review of the systems is carried out to ensure that all-important areas are covered and to identify further systems or information that may aid in diagnoses and guide treatment. The depth and time spent on systems review will depend on the urgency and acuity of the patients presenting complaint. In an emergent clinical scenario, a more focused approach would be taken based on the presenting complaint and directly related to the systems involved, such as cardiopulmonary for example. A more detailed review of the systems can take place when the patient has been stabilised. Table 1 provides an overview of a systems review as described by Seidel.2 Questions focus on eliciting information regarding the presence or absence of the symptoms described in the Table. If the patient confirms presence of a symptom more details and information need to be obtained to gain insight into the symptom and aid diagnoses. Bickley3 advocates beginning with a general question as each system is addressed. This approach focuses the patients attention and allows more specific questioning about the systems that maybe of concern. Examples of general questions include How

are your ears and hearing? or Any trouble with your lungs and breathing? . Common symptoms associated with cardiovascular disease include chest pain, dyspnoea, palpitations and oedema. According to Bickley3 when assessing cardiac symptoms it is important to quantify the patients baseline level of activity, eg. if the patient complains of shortness of breath ask does this occur at rest, during exercise or after climbing stairs. Quantifying baseline activity helps clarify the severity of the symptoms and their significance as the next steps in the plan of care are considered. Here we will focus on palpitations, shortness of breath and oedema. Table 2 represents common questions to ask in relation to the symptoms addressed Palpitations This symptom involves an awareness of the heartbeat and maybe described as skipping, racing, fluttering, pounding or stopping of the heart. They may be caused by an irregular heartbeat such as atrial fibrillation or by an arrhythmia such as atrial tachycardia or ventricular tachycardia for example. According to Bickley3 they do not necessarily mean the presence of heart disease. Shortness of breath Shortness of breath is a common symptom and is not solely specific to cardiovascular disease but can also be related to respiratory conditions. Shortness of breath may be classified as dyspnoea on exertion, dyspnoea at rest, orthopnoea (shortness of breath that occurs when lying down and improves when sitting up, normally caused by increased venous return to the right side of the heart when lying down) and paroxysmal nocturnal dyspnoea. Hall and Simpson4 define dyspnoea as the patient experiencing difficulty in getting their breath, causing unpleasantness and discomfort. Paroxysmal nocturnal dyspnoea is described as sudden episodes of shortness of breath that awakens the patient from sleep, normally occurs one to two hours after the patient has gone to bed. This symptom normally subsides by sitting or standing up and maybe associated with wheezing or coughing. Like orthopnoea it is normally caused by increased venous return to the heart when lying down but compared to other forms of dyspnoea it is a specific symptom for severe cardiac dysfunction. When exploring shortness of breath it is important to remember that due to variations in body shape, level of fitness, age, there is no absolute scale for quantifying dyspnoea. Instead it is vital to gain insight in to the symptom by assessing the symptom based on the patients level of activities. Oedema Woods 1 defines oedema as the abnormal accumulation of fluid in the interstitium and attributes causes to right heart failure, hypoalbuminaemia, excessive renal retention of sodium and water, venous stasis from obstruction or insufficiency,

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Table 1

Review of the systems

General symptoms Skin/hair and nails Chills, fever, cough, lethargy, tiredness, disturbance in sleep patterns, night sweats, usual weight - weight gain/ loss, any clothes that fit tighter or looser than before Integrity and condition of skin, hair and nails, rash or eruption, itching, pigmentation or texture change, excessive sweating, abnormal hair or nail growth /loss. Presence of splinter haemorrhages on the nails or clubbing, appearance of moles or change in existing moles Recent or persistent joint stiffness, aches or pains in the joints or muscles, any restricted movements, redness heat or swelling, bony deformities, problems with gait or walking, gout Frequent or unusual headaches and location. Dizziness, fainting, severe head injuries, moments of loss of consciousness Visual impairment blurring, diplopia, photophobia, recent change in vision or appearance of the eyes, use of eye drops, recent trauma to the eyes, family history of eye disease, wearing of glasses or contact lenses, last eye examination. Presence of hearing impairment and to which ear, pain, discharge, tinnitus (recent or chronic), vertigo, use of hearing aids Sense of smell, frequent colds, sinusitis, hay fever, epistaxis Hoarseness or change in voice, frequent sore throats, bleeding or swelling of the gums, recent tooth problems, soreness of the tongue or buccal mucosa, ulcers, impaired taste, use of dentures, last dental exam Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, diabetes, polyuria, polydipsia, changes in hair distribution, skin striae Males: Puberty onset, erectile dysfunction, emissions, testicular pain, libido, infertility, contraception Females: Onset of menstruation regularity, duration, dysmenorrhoea, last period, age at menopause, menopausal symptoms, post menopausal bleeding, libido, sexual difficulties, infertility, contraception, pregnancies, age at delivery, complications during pregnancy or delivery of baby Breasts any recent changes, pain, swelling, palpable lumps associated with menstruation/breast feeding Pain related to breathing, shortness of breath and when, orthopnoea, sputum (if any quantity and character), haemoptysis, exposure to tuberculosis, last chest x-ray if had one Circulation, cold extremities, chest pain or discomfort, precipitating factors, palpitations, fainting, shortness of breath, swelling of the ankles or legs, claudication, estimation of exercise tolerance, previous ECG or other cardiac tests, presence of high blood pressure, rheumatic fever, heart murmurs Anaemia, bruising, bleeding, thrombosis, thrombophlebitis, known abnormality of blood cells, transfusions Enlargement, tenderness, swelling or surgery Appetite (Likes/ dislikes, preferences/restrictions (religious, allergy, vegetarian/vegan, food intolerance) use of supplements (vitamins, protein shakes), quantity of caffeine containing drinks consumed per day), digestion, intolerances, dysphagia, heartburn, nausea, vomiting, haematemesis, bowel pattern, change in stool colour or consistency, flatulence, haemorrhoids, hepatitis, gallstones, polyps, tumour Dysuria, groin/suprapubic pain, urgency, frequency, nocturia, haematuria, hesitancy, dribbling, stress incontinence, hernias, sexually transmitted disease, history of urinary tract infections Weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory, fainting, seizures Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability

Musculoskeletal Head and Neck Eyes

Ears Nose Throat and mouth Endocrine/genital/ reproductive

Chest and Lungs Heart and blood vessels

Haematologic Lymph nodes Gastrointestinal

Genitourinary Neurological Psychiatric

lymphoedema, orthostatic oedema or increased capillary permeability. A weight gain of 10lb is normally indicative of five litres of extracellular fluid volume and precedes visible oedema. Interstitial oedema occurs in the dependent parts of the body such as feet, ankles and its location may vary according to patient position. If the patient is lying down oedema may accumulate in the sacral or scrotal region. When occurring in the lower limbs it is usually bilateral and symmetrical in appearance, painless and pitting in nature. 5 McMurray et al5 recommend daily weight monitoring as a means

of identifying sodium and water retention which can occur before oedema is evident. According the European Society of Cardiology Guidelines (2008) on the diagnosis and treatment of acute and chronic heart failure6 in cases of sudden unexpected weight gain of > 2kg in three days patients should alert their healthcare team as this is indicative of sodium and water retention Chest pain is the most common occurring symptom in the cardiovascular patient and will be addressed in part three of this series.
Kate O'Donovan is course co-ordinator for the postgraduate diploma in cardiovascular nursing in the Mater Hospital, Dublin

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Table 2

Common questions to ask regarding symptoms

Palpitations Are you aware of your heartbeat? What is it like? Ask the patient to tap out the rhythm with a finger Was it fast or slow? Regular or irregular? How long did it last? Did it start or stop suddenly? Have you had any difficulty breathing? Do you short of breath when walking on the flat or uphill? How many stairs can the patient climb before pausing for breath? How many pillows do you sleep with? Have you increased the number of pillows recently? Do you wake during the night with shortness of breath? Has the symptom altered or restricted the patients way of living and daily activities? If so, how? What relieves your breathlessness? Have you had any swelling anywhere? Where and anywhere else? When does it occur? Is it worse in the morning or at night? Do your shoes or waistband get tight? Have you had to let your belt out? Are the rings tight on your fingers?
4. Hall R, Simpson S. The cardiovascular history and physical examination. In: The ESC Textbook of Cardiovascular Medicine (2nd Ed). Oxford UK, 2009: 1-29. 5. Mc Murray J, Petrie M, Swedberg K, Komajda M, Anker S, Gardner R. Heart failure. In: The ESC Textbook of Cardiovascular Medicine (2nd Ed). Oxford UK 2009: 835-892. 6. Dickstein K, Cohen Solal A, Filipattos G et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2008; 29: 2388-2442.

Shortness of Breath

Oedema

References 1. Woods SL, Sivarajan Froelicher ES, Underhill Motzer S, Bridges EJ. Cardiac Nursing (5th Edn). Philadelphia: Lippincott Williams & Wilkins, 2005. 2. Seidel HM, Ball JW, Dains JE, William BG. Mosbys Guide to Physical Examination (5th Ed). USA: Mosby, 2003. 3. Bickley LS. The cardiovascular system. In: Bates Guide to Physical Examination and History Taking (10th Ed). Philadelphia: Lippincott Williams & Wilkins, 2009: 323-389.

Plant stanols and cholesterol July/August continuing education cardiology module Additional points from McNeil Nutritionals
WHIle McNeil Nutritionals welcomed the July/August article by Sally Whelan on plant stanols and cholesterol they wished to raise several points in response to it as follows: The cholesterol-lowering claims relating to plant stanols and sterols have recently been positively evaluated by the european Food Safety Authority (eFSA). These ingredients are among the first ingredients to receive positive opinions in relation to disease risk reduction claims in europe. eFSA confirmed, based on a comprehensive dossier of 30 gold standard clinical trials, that plant stanol esters have been shown to lower/reduce the risk of coronary heart disease (CHD)1 The US Food and Drug Administration has also authorised the use of a health claim to the effect that plant stanol and sterol esters may reduce the risk of CHD2 Three comprehensive scientific reviews have been completed recently by the eFSA and the european Commission (eC) has granted health claims based on the eFSA opinions3,4,5 The cholesterol-reducing efficacy of plant stanols/sterols is acknowledged internationally by authoritative Regulatory and Medical bodies, such as, the World Health Organisation/Food Agriculture Organisation, the International Atherosclerosis Society, The european Atherosclerosis Society and the european Society of Cardiology Plant stanols/sterols have an excellent safety profile.These ingredients have GRAS (Generally Regarded as Safe) status. More importantly, plant stanols have been satisfactorily consumed in foods for over 12 years by millions of consumers in europe. Several long-term studies have been conducted using plant stanols. Most notably, in 1995, a year-long study in Finland published in the New England Journal of Medicine demonstrated that the consumption of plant stanol ester is both efficacious and well-tolerated6 Plant stanol/sterol containing foods offer a proven dietary solution that allow one to actively lower lDl cholesterol levels as part of a balanced diet and lifestyle. Consumers can choose from a wide range of foods available of variable calorie count and cost Data from the recent Slan Report (Survey of lifestyle, Attitudes and Nutrition in Ireland) indicated that over three-quarters of the sample (82%) had raised cholesterol7 The first joint european guidelines for the management of dyslipidaemia published recently by the european Atherosclerosis Society and the european Society of Cardiology, lifestyle interventions are highlighted as the first step for managing lipids in all patients. Importantly in relation to plant stanols, the guidelines state that foods enriched with phytosterols may be considered for individuals with elevated total cholesterol and lDl cholesterol values in whom the total cardiovascular risk assessment does not justify the use of cholesterol lowering drugs.8
References 1. The eFSA Journals (2008) 852, 1-13 2. FDA Authorises New Coronary Heart Disease Claim for Plant Sterol and Plant Stanol esters September 5, 2000 3. Commission Regulation (eC) No 384/2010 of 5/5/2010. Official Journal of the european Union May 5,2010, l113/6. Commission regulation eC 384/2010 on the authorisation and refusal of authorisation of certain health claims made on foods and referring to the reduction of disease risk and to children's development and health 4. Commission Regulation No 983/2009 of 21/10/2009 Official Journal of the european Union Oct 22, 2009. l277/3. 5. Commission Regulation No 376/2010 of 5/5/2010 Official Journal of the european Union May 3, 2010, l111/3 6. Miettinen et al. Reduction of serum cholesterol with sito-stanol ester margarine in a mildly hypercholesterolaemic population. New england Journal of Medicine 1995; 333:1308-1312 7. http://www.slan06.ie/SlAN2007MainReport.pdf 8. eSC/eAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the european Society of Cardiology and european Atherosclerosis Society european Heart Journal (2011) 32, 1769-1818

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