history and physical report for a patient with heart disease

Once the doctor has completed your medical history, he or she will carry out a physical examination. The parts of the physical examination that are most helpful in diagnosing heart failure are: Measuring your blood pressure and pulse.

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What should be included in a family history of cardiac disease?

Family history of cardiac disease or stroke in a first degree relative aged less than 65. Describe any history of coronary artery disease List any cardiac catheterizations or history of coronary artery bypass surgery. List non-invasive studies such as nuclear stress tests or stress echo results.

What can history tell us about a patient's medical history?

Specific details from the history raise the probability of different diagnoses and direct further tests in a productive manner. Further diagnostic investigations—imaging, blood tests, pulmonary function studies, and even parts of the physical examination—depend on the history.

Does family history of cardiovascular disease predict cardiovascular responses to stress?

Family history of cardiovascular disease is associated with cardiovascular responses to stress in healthy young men and women. [Int J Psychophysiol. 2007] Family history of cardiovascular disease is associated with cardiovascular responses to stress in healthy young men and women.

Is there a link between family history and heart disease?

“Both the risk of heart disease and risk factors for heart disease are strongly linked to family history,” said William Kraus, M.D., a preventive cardiologist and research scientist at Duke University “If you have a stroke in your family, you are more likely to have one.” How much family history do you need to know?

What should be included in a history and physical?

Contents of a History and Physical Examination (H&P) 2. The H&P shall consist of chief complaint, history of present illness, allergies and medications, relevant social and family history, past medical history, review of systems and physical examination, appropriate to the patient's age.

What history assessment questions are important for a patient with a cardiac history?

Past medical history Note whether there have been any heart attacks, any history of angina and any cardiac procedures or operations (type and date of intervention and outcome). Previous levels of lipids if ever checked or known. Ask whether there is any history of rheumatic fever or heart problems as a child.

How do you write a present history of a patient?

It should include some or all of the following elements:Location: What is the location of the pain?Quality: Include a description of the quality of the symptom (i.e. sharp pain)Severity: Degree of pain for example can be described on a scale of 1 - 10.Duration: How long have you had the pain.More items...

What is physical examination of heart failure?

The parts of the physical exam that are most helpful in diagnosing heart failure are: Measuring blood pressure and pulse rate. Checking the veins in the neck for swelling or evidence of high blood pressure in the veins that return blood to the heart.

How do you take heart history?

5:5614:29How to take a FOCUSED cardiovascular history? - YouTubeYouTubeStart of suggested clipEnd of suggested clipSo the approach that i use to present my history is i start with a brief introduction of the patientMoreSo the approach that i use to present my history is i start with a brief introduction of the patient. So the patient's name their age their occupation.

How do you document a heart assessment?

Documentation of a basic, normal heart exam should look something along the lines of the following: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal.

How do you summarize a patient's history?

Summarising. After taking the history, it's useful to give the patient a run-down of what they've told you as you understand it. For example: 'So, Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing - particularly meat - and the whole thing's been getting you down.

What is history and physical examination?

The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

What is included in patient history?

A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.

How do you assess a patient with heart failure?

AdvertisementBlood tests. Blood tests are done to look for signs of diseases that can affect the heart.Chest X-ray. ... Electrocardiogram (ECG). ... Echocardiogram. ... Stress test. ... Cardiac computerized tomography (CT) scan. ... Magnetic resonance imaging (MRI). ... Coronary angiogram.More items...•

What physical exam findings can be found in congestive heart failure?

Signs that represent left sided failure include cool clammy skin, cyanosis, rales, a gallop rhythm, and a laterally displaced PMI. Signs that represent right sided failure include an elevated JVP, pedal edema, ascites, hepatomegaly, a parasternal heave and hepatojugular reflux.

What is the first step in examination of the cardiac system?

The cardiac examination consists of evaluation of (1) the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous pulse and auscultation for cervical venous hums; (3) the precordial impulses and palpation for heart sounds and murmurs; and (4) auscultation of the heart.

What questions are asked in a cardiac assessment?

You will also want to ask about the patient's history of heart disease, when and how it was treated, last EKG, stress tests, and serum cholesterol levels. Ask the patient the reasons for any previous hospitalizations and the nature of the treatments received while in the hospital.

What data would be significant to obtain when performing a focused cardiovascular history of a patient?

A cardiovascular and peripheral vascular system assessment includes collecting subjective data about the patient's diet, nutrition, exercise, and stress levels; collecting the patient's and the patient's family's history of cardiovascular disease; and asking the patient about any signs and symptoms of cardiovascular ...

What questions should I ask a patient with chest pain?

Questions aimed at identifying the patient with possible ACS:Where is your pain? (location)Does it go anywhere else? (radiation)When did it start? (onset)How long has it lasted? (duration)How bad is it? (severity on pain scale)Does anything make it better or worse?Have you taken any medication to relieve it?More items...

Why is cardiac assessment important?

A thorough assessment of the heart provides valuable information about the function of a patient's cardiovascular system. Understanding how to properly assess the cardiovascular system and identifying both normal and abnormal assessment findings will allow the nurse to provide quality, safe care to the patient.

What to tell your doctor about heart disease?

Tell your doctor if your parents, sisters, brothers, children, grandparents, grandchildren, aunts, uncles, nieces, or nephews have or have had. Based on this information, your doctor may suggest steps to prevent or treat heart disease. If you have been diagnosed with heart disease or related conditions, it is important to tell your family members.

What is an external icon?

external icon. Heart bypass. external icon. or other heart surgery. Based on this information, your doctor may suggest steps to prevent or treat heart disease. If you have been diagnosed with heart disease or related conditions, it is important to tell your family members.

What to include in a family history?

Include your parents, sisters, brothers, children, grandparents, grandchildren, aunts, uncles, nieces, and nephews. Make sure you include both your mother’s and father’s sides of the family. Note which relatives have had heart disease, related conditions, or procedures and the age at which they were diagnosed or treated.

Can you develop heart disease from a family history?

If you have a family health history of heart disease , you are more likely to develop heart disease yourself. Different types of heart disease and related conditions, like high blood pressure and high blood cholesterol, can run in families.

Data and Statistics

Behavioral Risk Factor Surveillance System (BRFSS) Information about health conditions and behaviors in the United States from the BRFSS, the world’s largest ongoing telephone health survey.

Other Organizations

Please see the following websites for additional information about heart disease:

What does family history do?

Your family history provides a picture of the environment and genetics in place when these diseases occurred. “You can’t counteract your genetics,” Dr. Kraus said, and so if you have a history you must do what you can to change your environment. That means lowering your risk by changing behaviors that can increase your chances ...

Why is knowing your family's health history important?

Knowing your family’s health history can help you avoid both heart disease and stroke – the No. 1 and No. 5 causes of death in America. “Both the risk of heart disease and risk factors for heart disease are strongly linked ...

How many Hispanics have high blood pressure?

face higher risks for high blood pressure, diabetes and stroke. Statistics also indicate that about 1 in 3 Hispanics will have high blood pressure, and nearly half will battle high blood cholesterol.

What are the risks of having a clean bill of health?

For example, statistics show that African-Americans (PDF) (link opens in new window) face higher risks for high blood pressure, diabetes and stroke.

What is a crackle in music?

Crackles, still often referred to as “rales” in the United States and “crepitations” in Great Britain, consist of a series of short, explosive, nonmusical sounds that punctuate the underlying breath sound; fine crackles (Audio 16-4) are softer, shorter in duration, and higher in pitch than coarse crackles (Audio 16-5).

What is it called when you can't take a supine position?

The inability to assume the supine position (instant orthopnea) is characteristic of paralysis of both leaves of the diaphragm. Dyspnea soon after assuming the supine position also may be associated with other conditions, such as arteriovenous malformation, bronchiectasis, and lung abscess.

What is a stridor?

Stridor is a high-pitched continuous sound produced by turbulent flow in the extrathoracic airway, which—in contrast to wheezing—is louder and longer during inspiration than expiration (Audio 16-12). Stridor has many causes,90some of which are life-threatening and need immediate attention (see Chapter 49).

Why is occupational history included in social history?

Because of its relevance and importance in the evaluation of patients with known or suspected pulmonary diseases, the occupational history is included as a separate component of the social history. Travel history, also included in the social history, is helpful in diagnosing certain lung diseases.

What are the disadvantages of electronic medical records?

The disadvantages of electronic medical records include “information overload” and potential loss of privacy. Software downtime can be crippling.

Why is experience important in clinical practice?

Experience is valuable in the acquisition of clinical pattern recognition and in accumulating clinical knowledge . Although interviewing skills can be systematically learned,12acquiring the art of adept history taking and physical examination is a lifelong process that is incrementally improved by careful practice.

Can fremitus be detected over the chest wall?

Occasionally, fremitus over part of the chest wall can detect the presence of airway secretions (rhonchal fremitus) or an underlying pleural friction rub (friction fremitus). In examining the heart the examining physician should always search for an apical impulse, heaves and lifts, thrills, and palpable valve closure.