Cardiovascular Subjective Data Collection Guide

Posted on Aug 25, 2024 in Medicine & Health

1. Any chest pain or tightness?

Onset: When did it start? How long have you had it this time? Has this type of pain occurred before? How often?
Location: Where did the pain start? Does the pain radiate to any other spot?
Character: How would you describe the pain? Crushing, stabbing, burning, aching, heaviness? (Allow the patient to describe before you suggest. Note if they use a clenched fist to describe the pain.)
Triggers: Is the pain brought on by activity? If so, what kind? Rest, after eating, during sexual intercourse, with cold weather?
Associated Symptoms: Sweating, pale skin, heart skipping a beat, shortness of breath, nausea or vomiting, racing heart?
Aggravating Factors: Is the pain made worse by moving the arms or neck, breathing, lying flat, etc.?
Relieving Factors: Is the pain relieved by rest or medicine? How much?

2. Dyspnea: Any shortness of breath?

3. Orthopnea: How many pillows do you use when sleeping or laying down?

4. Cough: Do you have a cough?

Duration: How long have you had it?
Frequency: Is it related to a time of day?
Type: Is it a dry, hacking, barking, hoarse, or congested cough?
Mucus: Do you cough up mucus? If so, what color? Any odor or blood?
Triggers: Is the cough associated with any activity or position, anxiety, talking?
Aggravating/Relieving Factors: Does any activity make it better or worse? (Walking, sitting, exercise) Is it relieved by rest or medication?

5. Fatigue: Do you seem to tire easily? Able to keep up with family or co-workers?

Onset: When did the fatigue start? Was it sudden or gradual? Have any recent changes occurred in your energy level?
Pattern: Is fatigue related to a time of day: all day, morning, night?

6. Cyanosis or Pallor: Have you ever noticed your skin turning blue or ashy?

7. Edema: Any swelling in your feet or legs?

Onset: When did you first notice this? Any recent changes?
Timing: What time of day does the swelling occur? Do your shoes feel tight at the end of the day?
Severity: How much swelling would you say there is? Are both legs equally swollen?
Relieving Factors: Does swelling go away with rest, elevation, after a night’s sleep?
Associated Symptoms: Any associated symptoms such as shortness of breath? If so, does this occur before or after swelling?

8. Nocturia: Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change?

9. Past Cardiac History:

Any history of hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever, or unexplained joint pains as a child or youth?
Any recurring tonsillitis or anemia (lack of enough red blood cells)?
Ever had heart disease? When was this? Treated by medication or heart surgery?
Last ECG, stress ECG, serum cholesterol measurement, other heart tests?

10. Family Cardiac History: Any family history of hypertension, obesity, diabetes, coronary heart disease, sudden death at a young age?

11. Patient-Centered Care:

Nutrition: Please describe your usual daily diet (amount of calories, use of salt). What is your usual weight? Has there been any recent change?
Smoking: Do you smoke cigarettes or use any other tobacco products? At what age did you start? How many packs per day? How many years have you smoked this amount? Have you ever tried to quit? If so, how did this go?
Alcohol: How much alcohol do you usually drink each week or each day? When was your last drink? How many drinks during that episode? Have you ever been told you have a drinking problem?
Exercise: What is your usual amount of exercise each day or week? What type of exercise? (Light, moderate, heavy)
Drugs: Do you take any hypertension medication, beta-blockers, calcium channel blockers, digoxin, aspirin, anticoagulants, over-the-counter medications, or street drugs?
If they take aspirin (men age 45 to 79 or women 55 to 79) encourage them to take vitamin D; deficiency increases the risk of cardiovascular disease and is associated with hypertension.

If Aging Adult:

Do you have any known heart or lung disease? What efforts to treat this have been started? Any unusual symptom changes recently? Does illness interfere with your daily living?
Do you take any medications? Are you aware of side effects? Have you stopped taking any medication? If so, why?
Does your home have stairs? How often do you need to climb them? Does this impact your daily living? Do you have the ability to maintain nutrition? Are all of your daily needs met?
Education level? Last grade completed? Other training?
What religion do you practice? What are your personal strengths?
Do you need help with feeding, hygiene, dressing, walking? Are those needs met?
What is your sleeping pattern like? Any daytime naps? Any sleep aids used?
Who is present at mealtime with you?
What is your role in the family?
Support system? What’s that like for you?
How do you cope with stress? Is that helpful?
Daily caffeine intake?