Cardiovascular Assessment: Subjective Data

Subjective Data Chest Pain Dyspnea Orthopnea Cough Fatigue Cyanosis Edema Nocturia Past Medical History Family history Risk factors Chest Pain When did it start? How long have you had it this time? Have you had this type of pain befor? How often? How would you describe it: crushing, stabbing buring, viselike? What brought on this pain? Activity, rest, emotional upset, after eating, during sex, cold weather? Any associated symptoms? Grey or pail skin, sweating, heart skips beat, shortness of breath, nausea or vomiting, racing of heart? Pain made worse by moving arms or neck, breathing, lying flat? Pain relieved by rest or nitroglycerin? How many tablets? 00:20 01:35 Dyspnea Shortness of breath What type of activity and how much brings on SOB? How much activity brought it on 6 months ago? Does the SOB come on unexpectedly? Duration: Constant or does it come and go? Seem to be affected by position: lying down? Awaken you from sleep at night? Does the shorness of breath interfere with ADLs? Orthopnea The need to assume a more upright position to breathe How many pillows do you use when sleeping or lying down? Cough Duration: how long have you had it? Frequency: Is it related to time of day? Type: Dry, hacking, barky, hoarse, or congested? Do you cough up mucus? Color? Any odor? Any blood? Associated with: activity, position (lying down), anxiety, talking? Does activity make it better or worse (sit, walk exercise)? Relieved by rest or medication? Fatigue Do you seem to tire easily? Able to keep up wit your family and co-workers? Onset: Whe did fatigue start? Sudden or gradual? Has any recent change occurred in energy level? All day, morning, evening? Cyanosis Ever noted your facial skin turn blue or ashen? Edema Any swelling of you feet and legs? When did you first notice this? Any recent change? What time of day does the swelling occur? Do your shoes feel tight at the end of the day? How much swelling would you say there is? Are both legs equally swollen? Does the swelling go away with: rest, elevation, after a night's sleep? Any associated symptoms: SOB? Does the shortness of breath occur before leg swelling or after? Nocturia Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change? Past Medical History Any past history of: hypertension, elevated cholesterol or tryglycerides, heart nurnur, congenital heart disease, rheumatic fever or unexplaine djoint pains as a child or youth, recurrent tonsillitis, anemia? Ever had heart idsease? When was this? Treated by medication or heart surgery? When were your last ECG, stress ECG, serum cholesterol measurements, or other heart tests? Family history Any family history of: hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age? Risk factors Please describe your usual daily diet. (Note: basic food groups, amount of calories, cholesterol, salt) What is your usual weight? Has there been any recent change? Smoking: Do you smoke cigarettes or other tobacco? What age did you start? How many packs per day? For how many years? Have you ever tried to quit? How did quitting go? Alcohol: How much alcohol do you usually drink each week or day? When was your last drink? What was the number of drinks during that episode? Have you ever been told you had a drinking problem? Exercise: What is your usual amount of exercise each day or week? What type of exercise? What is your usual intensity: light, moderate, heavy? Drugs: Do you take any antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants, OTC or street drugs?