- CC:
- Site: where? Radiates anywhere else?
- Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
- Duration: how long does it last?
- Timing: specific time of the day\night? How frequent?
- Character: dull, sharp, stabbing, burning, pressure-like?
- Aggravating\relieving factors: rest vs exertion? Breathing\coughing? Posture (leaning forwards vs laying down), eating, pain killers, nitroglycerin?
- Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, wt loss, loss of appetite, night sweats, chills, lymphadenopathy?
- Cardiac: sweating, palpitation, loss of consciousness, LL swelling, claudication?
- Resp: cough, SOB, PND?
- GI: abdominal pain, N\V, heartburn, change of BM?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM, DLP)
- Prev heart attacks or strokes
- Heart or lung diseases
- Infections, malignancy
- Medications: NSAIDs, NTG, aspirin, anticoagulants (heparin, warfarin)
- Surgery (prev cath or CABG), hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Family Hx of premature CAD?
- Family Hx of sudden cardiac death?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx, contact with sick pts?
- Diet, exercise