The Checklist in History Taking

The Big Heart Disease Lie

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Traditionally, students have learned to take a history by memorizing a standard checklist and have been warned that a checklist should not be used in front of the patient.

When the opinions of patients were solicited concerning the reading of questions in front of them, it was found that patients either did not recall that the physician had been reading the questions, or if the patient had been to other doctors, they would often claim that it was the first time they had a thorough history taken.

Some of the advantages of reading an organized list of questions are:

1. The final history as written on paper may be very short because no negative findings need be recorded; otherwise it is necessary to list all negative findings for the reader to know what has been asked.

2. The history can be taken more rapidly with a list of questions than without, because you are not trying to recall your place as would be necessary with a memorized checklist, especially if the patient rambles.

3. Upon leaving the patient, there is no feeling of insecurity due to fear that you may have forgotten to ask something.

Cardiological diagnosis can be learned from the checklist in this chapter. An asterisk before each important symptom refers the physician to another page that lists further questions suggesting a differential diagnosis. In this way, physicians can take a good chief complaint history, and they also learn the differential diagnosis of all important symptoms.

The checklist proposed here is not to be used as a "check-off" list with yes or no answers but rather as a "reminder" list. The patient's answers to the reminder list can be taken down in an unorganized form on separate sheets and later reorganized under a few headings, such as:

1. Chief complaint (why patient came or was referred, and who referred). How long before seeing you or before admission?

2. History of chief complaint or complaints. For example, if the patient has chest pain, write the complete story of the chest pain from the follow-up questions of the checklist.

3. Other etiologies pertinent to the chief complaint. These headings should contain the word "Possibilities"; for example, if the patient has known valvular disease, "Rheumatic Heart Disease Possibilities" would be an appropriate heading.


If the patient has had cardiac surgery, indicate the date, place, type of operation, name of surgeon. Were cardiac symptoms alleviated? Catheterization results? Were there surgical complications, e.g., emboli or infections? Treatment after surgery, e.g., anticoagulants?

Left Ventricular Failure or High Left Atrial Pressure Possibilities

Note: An asterisk before a question indicates that if the patient answers yes to that question, you should turn to a later page that gives the differential diagnosis of that symptom by means of more questions.

*1. Dyspnea, cough, or wheeze on exertion, on hills or on stairs? (If yes, see p. 7.)

*3. Paroxysmal nocturnal dyspnea? (If yes, see p. 9.)

4. Heart failure symptoms in pregnancy? (If in first trimester, may be due to pla-cental product.)

5. Therapy with low-salt diet or drugs? (Indicate dose and if helped.) Why stopped? Side effects? If digitalis, did patient have gastrointestinal symptoms, weakness [1], faintness, dizziness, visual disturbances, or palpitations? If diuretics (loop or thiazide?), were there muscle cramps or weakness? Preload or afterload reducers used? Drugs used that could precipitate borderline failure, e.g., beta blockers, calcium blockers, or disopyramide?

Peripheral Venous Congestion or Pseudo Right Heart Failure Possibilities

*1. Peripheral edema, maximum and minimum weight? (If yes, see p. 9.)

2. Abdominal swelling? (If before orthopnea, consider tamponade. (See p. 5 for tamponade symptoms.) Right upper abdominal pain with exercise or bending discomfort? (Suggests hepatomegaly.)

Low Output State Possibilities

1. Weakness or fatigue? Afternoon nap necessary? When last able to do normal activities comfortably? Most strenuous activity in past few months?

2. Cold extremities? How long?

3. Excess perspiration? (A sign of failure in infants.) With warm hands, suggests hyperthyroidism; with cold hands, suggests neurocirculatory asthenia (psycho-neurosis) or failure.

4. Insomnia? (May indicate Cheyne-Stokes respiration with hyperpnea on dozing.)

5. Nocturia with polyuria? (May be daytime failure compensating at rest.)

6. Orthostatic faintness.

Fixed Output State Possibilities

*1. Syncope, presyncope, or dizziness? (If yes, see p. 7.)

Chamber Enlargement Possibilities

1. Trepopnea? (Cannot lie horizontally in bed, but not due to heart failure.)

*2. Palpitations or awareness of heart beat? (If yes, see p. 13.)

3. Told of enlarged heart? (From ECG, X-ray, echocardiogram, or physical examination?) Date of last chest X-ray (portable?), echocardiogram, and ECG?


Rheumatic Heart Disease Possibilities

1. History of rheumatic fever with joint pains or chorea (twitches or clumsiness for a few months)? Red, swollen joints, or only fever plus murmur as a child? Therapy with prophylactic penicillin? Family history of rheumatic fever? Murmur history (for school examination, operation, insurance, or military service)? Was it the result of cardiac catheterization or an echocardiogram? When and where done? Were there "growing pains" or nocturnal leg pains (not rheumatic)?

Complications of Rheumatic Heart Disease

1. If mitral stenosis; hemoptysis, hoarseness, Ortner syndrome, or cardiovocal syndrome. (pressure of large left atrium on large pulmonary artery against recurrent laryngeal nerve), or embolic phenomena (hematuria, pleurisy, unilateral weakness, or partial vision loss in one eye due to calcium emboli from aortic valve)?

2. If aortic stenosis: exertional dyspnea, syncope, or angina (classic aortic stenosis triad)?

Boldface type indicates that the term is explained in the glossary.

3. If aortic regurgitation: nocturnal angina or awareness of large pulsations in arms, neck, or chest?

4. If infective endocarditis: severe night sweats, dental work, or embolic phenomena, such as back pain or cerebrovascular accident?

Ischemic Heart Disease Possibilities

*1. Chest pain, tightness, or pressure? (If yes, see p. 11.)

2. Previous myocardial infarction? Symptoms and hospital course? Postinfarction drugs, such as beta blockers and aspirin, used?

3. Risk factors:

a. Major: hypertension, high cholesterol or triglycerides, low HDL, smoking, family history of infarction at early age?

b. Minor: diabetes, premature menopause, intermittent claudication, gout, high uric acid [2]? Is patient type A (slightly hostile, aggressive, and impatient)? Stressful job or home life? On diet or taking drugs to decrease lipids?

c. Marked postprandial somnolence (suggests severe hypertriglyceridemia, or insulin resistance.)

Hypertensive Heart Disease Possibilities

High Output Failure Possibilities

1. Anemia: under treatment? Heavy periods, bleeding piles or melena? Upper gastrointestinal surgery (B12 deficiency)? Sickle cell disease history? Lead contact? Radiation or anticancer drugs?

2. Thyrotoxicosis: heat intolerance, warm skin, weight loss, polydipsia, polyuria, excess perspiration, frequent stools, restlessness, muscle weakness on climbing, or palpitations?

3. Beriberi: evidence of alcoholism with a poor diet? Bartender job? Fad diets or peripheral neuritis? Long time on large-dose diuretics?

Cor Pulmonale Possibilities

1. Chronic obstructive pulmonary disease: smokes? Easier to breathe leaning forward? Were pulmonary function tests performed? Told of emphysema or experienced chronic cough with wheezing and sputum? Coal miner? Abnormal chest X-ray? Marked obesity? Pickwickian syndrome.

2. Asthma: is wheezing helped by bronchodilators? Seasonal dyspnea?

3. Pulmonary emboli: is there is a history of phlebitis or oral contraceptives? Sudden dyspnea at rest with pleurisy or faintness with cold sweat or hemoptysis? Recently on long auto or airline trip or had trauma or surgery?

4. Primary pulmonary hypertension: Raynaud's phenomenon [3] or fixed output symptoms?

Pericarditis, Effusion, Constriction, or Tamponade Possibilities Etiologies

Chest trauma: postcardiotomy or postmyocardial infarction syndrome (Dressier's syndrome) with fever, pleurisy, and polyserositis, as long as 2 months after surgery. Chest radiation, uremia, metastatic carcinoma, lymphoma, leukemia, lupus, rheumatoid arthritis, tuberculosis contact, or recent viremia. Drugs: procainamide, hydralazine, or isoniazid.

Symptoms of Pericarditis

1. Chest pain on motion, swallowing, or inspiration.

2. Past history of pericarditis (idiopathic type may be recurrent).

3. Epigastric pain for a few days before chest pain.

Symptoms of Tamponade

1. Dyspnea on exertion, especially if it stops immediately on stopping exertion.

2. Edema or abdominal swelling beginning before or simultaneously with dyspnea on exertion is highly suggestive of tamponade.

Myocarditis, Endocarditis, and Other Heart Disease Possibilities

1. Recent influenza-like illness with myalgia?

2. Infective endocarditis: drug addiction, fevers, surgical or dental procedures, or recent back pain?

3. Collagen disease: Raynaud's phenomenon, dysphagia, arthritis, or arthralgia?

4. Ankylosing spondylitis: hip, sciatic, or back pain, especially on awakening or increasing with coughing?

5. Hypophosphatemia: high intake of phosphorus-binding antacids, e.g., aluminum hydroxide? Acute alcohol excess?

6. Hypertrophic cardiomyopathies: sudden death in family? Angina or syncope after exercise? Dyspnea not helped by digitalis?

7. Luetic aortic regurgitation or aneurysm: veneral disease or hoarseness (aneu-rysm compressing recurrent laryngeal nerve)?

Infiltrative Cardiomyopathies

1. Hemochromatosis: diabetic? Skin color changes? Liver failure: impotence, upper abdominal pain, gynecomastia, or arthritis? Frequent transfusions?

2. Sarcoidosis: syncope (from atrioventricular [AV] block), chest X-ray abnormality, kidney stones, or eye symptoms (uveitis)?

3. Amyloidosis: postural hypotension, peripheral neuropathy, or skin lesions, especially if pruritic or bleed when scratched? Angina? Weakness? Dysar-thria? Purpura?

4. Parasitic disease: trichinosis or Chagas' disease (eaten rare meat or been in foreign country)?

5. Hypothyroidism or myxedema. See follow-up questions 4 under hormonal causes. See under Peripheral edema, hormonal causes, p. 9.

Cardiac Tumors

1. Atrial myxoma: embolic phenomena, fevers, arthralgias, skin lesions, paresthesias, presyncope or syncope with changes of posture?

2. Carcinoid: diarrhea, wheezing, or flushing of face, neck, and front of chest for minutes or days?

Congenital Heart Disease Possibilities To Be Asked Only if Patient Is an Infant

1. Frequent pneumonias (suggests increased lung blood flow)?

2. Excess perspiration (sign of failure in infants)?

3. Mother aware of infant's heartbeat or vibration or thrill?

To Be Asked if Patient Is an Infant, Child, or Adult

1. Murmur at birth? (Suggests stenotic lesion. If delayed a few weeks, suggests left-to-right shunt).

2. Results of cardiac catheterization.

3. Pregnancy with rubella? (Suggests persistent ductus, ventricular septal defect, atrial septal defect, stenosis, pulmonary arterial [not valvular] stenosis, or tetralogy of Fallot.)

4. Normal growth and development? (High birth weight suggests transposition.)

5. The mother's pregnancy: If viral illness, may produce myocarditis in newborn. If diabetes, suggests transposition. Age of mother when pregnant? (If in 40s, suggests tetralogy of Fallot.)

6. Family history of congenital heart disease or murmur?

7. Cyanosis? From birth, suggests transposition or tetralogy. If delayed until teens or middle age, suggests Eisenmenger's syndrome or Ebstein's anomaly. If with crying, feeding, or warm bath, or if only with syncope, suggests tetralogy. If differential cyanosis and clubbing (fingers pink but toes blue), suggests duc-tus with Eisenmenger's syndrome. Frequent phlebotomies?

8. Stroke? (Consider embolus from endocardial fibroelastosis, idiopathic cardi-omyopathy, or paradoxical embolus from right atrium. If cyanotic, consider cerebral abscess.)

9. Crying during feeding: suggests angina due to anomalous left coronary artery.

To Be Asked Only if Patient Is a Child or Adult

1. Hoarseness? (Suggests large ductus or primary pulmonary hypertension.)

2. Mental retardation? (Consider the Down syndrome or supravalvular aortic stenosis.)

3. Hypertrophic osteoarthropathy with swelling, pain, warmth, and lower extremity tenderness? (Consider ductus with Eisenmenger's syndrome.)

4. Recurrent bleeding from nose, lips, and mouth with melena and hemoptysis due to hereditary hemorrhagic telangiectasia or Rendu-Osler-Weber disease? (Suggests pulmonary AV fistula, especially if cyanotic.)

5. Presyncope or syncope? If on exertion, suggests aortic stenosis or primary pulmonary hypertension; if with straining or after sleep and with cyanosis, suggests tetralogy. If at rest, consider epilepsy or complete atrioventricular block with Stokes-Adams attack.

6. Squatting? (Suggests tetralogy, pulmonary atresia, or Eisenmenger's syndrome.)

7. Headaches, epistaxis, leg fatigue, cold legs, or claudication? (Suggests coarctation.)


1. If Patient Says Yes to Dyspnea on Exertion Orientation

When was the patient last able to do normal activities comfortably? How far can the patient walk on the level or stairs before dyspnea? Is walking rate slower? Can patient walk and talk simultaneously? The most strenuous activity performed in the past few months?


1. Failure: effect of digitalis, diuretics, low salt intake, or afterload treatment? Is there orthopnea, paroxysmal nocturnal dyspnea, or cough and wheeze on exertion? (If suddenly worse, suggests ruptured chordae, atrial fibrillation, pulmonary embolus, or acute infarction). If on digitalis, any gastrointestinal or visual symptoms? Weakness, faintness, dizziness, or palpitations?

2. Anginal equivalent: (One-third of patients with angina have simultaneous dyspnea without heart failure.) Lasts 10-20 min? With nausea, perspiration, or occasionally with angina? Had Holter monitor?

3. Arrhythmia: with abnormal rhythm or palpitations? Begins and ends suddenly? Ever checked pulse when short of breath?

4. Anxiety: nervous breakdown, or tranquilizer history, or hyperventilated with paresthesias, cold perspiration, palpitations, and days without dyspnea? (Suggests neurocirculatory asthenia.)

5. Pulmonary dysfunction: associated with weight gain? Asthma: wheezes helped by bronchodilators? Evidence of emphysema, smokes, coughs with sputum? Pulmonary function results? Pulmonary embolism: sudden shortness of breath, syncope with hemoptysis, chest pains, cold sweats, phlebitis, or varicose veins? Is patient pregnant or on contraceptive pills? Recent long trip? Pneumothorax: sudden shortness of breath or inspiratory chest or shoulder pain with dry cough?

6. Severe anemia: has patient had bleeding ulcers, hemorrhoids, or excessive bleeding from the uterus; melena; sickle cell disease; gastrectomy? Been treated with vitamin B12 or iron? Pins-and-needles sensation?

7. Compression of pulmonary artery or bronchus: results of last chest X-ray?

2. If Patient Says Yes to Orthopnea Orientation

When did it begin? Spontaneous, or told by physician to use more pillows? Severity

How high must the head be? How soon after the patient lies down does it begin? (Orthopnea begins in less than a minute.)


1. Trepopnea: horizontal discomfort not due to heart failure, occasionally due to feeling large heart against bed when on left side, or due to musculoskeletal pain or dizziness, or to hypoxia from lying on side of lung with pneumonia or cancer.

2. Markedly decreased vital capacity: no complete relief at any chest elevation (as with severe mitral stenosis)? Relieved if the patient remains supine? (Suggests pulmonary hypertension.)

3. If Patient Says Yes to Paroxysmal Nocturnal Dyspnea (PND) Orientation

When did PND begin? How frequently does it recur? Due to LV Failure a. How long after the patient is asleep does it occur? (Redistribution of fluid takes 2-4 h to raise left atrial pressure.)

b. Does the patient dangle legs to get relief? (lf not, it is not PND.)

c. Duration? (It should take 10-30 min to redistribute fluid back into tissue.)

d. With cough, wheezing, or frothy, pink sputum?

Not Due to LV Failure a. Occurs also during the day? (If so, then it is not PND.)

b. No effect of digitalis, diuretics, and afterload therapy?

c. Awakens with palpitations, chronic cough, postnasal drip, or nocturia before shortness of breath noted?

d. Awakens with chest pain or tightness? (Nocturnal angina.)

4. If Patient Says Yes to Peripheral Edema Orientation

When did it begin? Shoes too tight? Does edema extend to the knees? Is it gone in the morning? Effect of digitalis, diuretics, and afterload treatment?


1. Cardiac: helped by cardiac-failure drugs?

2. Stasis or obstructive edema: began with weight gain or pregnancy? Tight panty girdle or varicose veins or phlebitis? Shirt collar tight and face swollen? (Suggests superior vena cave obstruction.) Abdominal swelling? (Suggests constriction, tamponade, or ovarian cancer.)

3. Hormonal causes: premenstrual syndrome; breast fullness, headache, and mood changes? On estrogens or contraceptive pills? Aldosteronism: hypertension, weakness, tetany, paresthesias, or a high licorice intake? Myxedema: voice change, dry skin, cold intolerance, sluggishness, weight gain, constipation, menorrhagia, or decreased hearing? Thyroid tests?

4. Intermittent idiopathic edema of women: menstrual disorders?

5. Drug-induced: on vasodilators, nonsteroidal anti-inflammatory agents calcium blockers, or estrogens?

6. Renal: facial and hand edema? Worse in the morning?

7. Cirrhosis: alcoholism, hepatitis, or jaundice?

8. Constriction: Did edema begin before the dyspnea?

9. Severe COPD due to: (a) high intraabdominal pressure durinq expiration, as well as inspiration; (b) high CO2 dilating afferent renal arterioles more than efferents.

5. If Patient Says Yes to Presyncope, Syncope, or Dizziness Orientation

When did it begin? Duration and frequency? By dizziness does the patient mean faintness, loss of balance, lightheadedness, blurred vision, sinking feeling, floating sensation, unsteadiness, swaying, swimming, or vertigo?


1. Epilepsy: how long unconscious? Is mind clear after? Prodrume? Began with a twitch? Sore tongue, incontinence, or head trauma? Family history? Were convulsions witnessed? Ever had EEG or neurological examination? Were anticonvulsants administered?

2. Acute infarction: preceded or followed by chest or arm discomfort, shortness of breath, or perspiration?

3. Hysterical: always in the presence of someone else? Paresthesias or dyspnea also (hyperventilation)? Ever injured self?

4. Orthostatic: after prolonged bed rest? On antihypertensives or dialysis? Auto-nomic abnormalities: diabetes, nocturnal diarrhea, impotence, peripheral neuritis, or absent sweating? Worse if hot or fatigued? Large varicose veins?

5. Excess bleeding: piles, melena, menorrhagia, on anticoagulants, trauma? (A ruptured spleen may produce symptoms a week after trauma.)

6. Carotid insufficiency: unilateral blindness, weakness, paresthesias, dysarthria, or aphasia for a few minutes or hours?

7. Vasovagal: preceded by nausea or sinking epigastric feeling? Skin wet and pale after? Associated with tight collar, head turning, or hyperextension? (Suggests hypersensitive carotid sinus.)

8. Fixed output or obstruction to flow: known pulmonary hypertension or stenosis? Syncope after exercise cessation? (Suggests hypertrophic obstructive cardiomyopathy.) Atrial myxoma, fevers, embolic phenomena, or dyspnea with changes of posture?

9. Stokes-Adams attacks: flushed after the attack and slow pulse noted at the time?

10. Pulmonary embolism: preceded by lightheadedness with or without dyspnea and pleuritic pain, hemoptysis, or cold sweat? Long trip sitting?

11. Cough or micturition syncope?

12. "Drop attacks" (sudden loss of postural tone without losing consciousness): a deadweight when someone tried to raise body? (Pressure on soles of feet regains postural tone.)

13. Stroke: unilateral weakness or slurred speech?

14. Cardiac syncope: with palpitations? Long Q-T syndrome (precipitated by qui-nidine, disopyramide, exercise, fatigue, anxiety, or a sudden loud noise or preceded by nausea or headache)? Erythromycin-type drug?

15. Sick sinus syndrome: history of slow pulse or palpitations as in bradycardia-tachycardia syndrome?

16. Cyanotic heart disease, tetralogy of Fallot.

6. If Patient Says Yes to Chest Pain or Pressure Orientation

When did it begin, and how often does it recur? Longest and shortest time between episodes?

1. Site: (Ask patient to show you. Do not ask patient to point. If classic angina, the fist or hand will be over sternum or across chest. If the patient points, it is likely nonanginal.) Is there radiation? Several chest pains? Classic angina radiates to medial side of forearm to thumb. May radiate to jaw, anywhere on abdomen, to surgical scar or interscapular area.

2. Character: classic angina with tightness and pressure? (Any kind of discomfort can be angina.)

3. Nonangina: points to site with one finger? Lasts less than 5 s or more than 30 min? Increases with inspiration, local pressure, or one movement of the arms or chest? Relieved immediately when patient lies down? Reaches maximum immediately?; (Suggests dissection.) Seeks relief by walking? Radiates to lateral forearm or thumb?


1. Coronary obstruction: classic angina precipitated mainly after first exertion in morning, by food or cold air and anything that increases heart rate or afterload. With pallor, flatulence, nausea, sweating, or dyspnea? Relieved by drugs that decrease preload, afterload, heart rate, or inotropism? Risk factors: diabetes, hypertension, artificial menopause, contraceptive use, smoking, gout, intermittent claudication, previous infarction, family history of coronary disease, increased cholesterol or low HDL?

2. Vasospastic angina (Prinzmetal's angina): at rest, especially at night toward morning? Precipitated by cold air? Good and bad days?

3. Unstable angina: occurs more frequently with less provocation, lasts longer, or at rest?

Noncoronary Causes

1. Pericarditis: worse supine and with inspiration? Relieved by leaning forward? Worse with leg elevation, swallowing, or extending neck. May be referred to left neck, shoulder, and arm by phrenic nerve. Also to abdomen, especially in children. Unlike angina, it is less likely to be retrosternal and more likely left-sided. It may be influenced by each heart beat.

2. Congenital absence of pericardium? Brought on by lying on the left side? Lasts a few seconds or minutes? Relieved by changing position in bed?

3. Esophagitis or spasm: burning pain on eating or Iying down? Acid reflux (water brash)? Relieved by antacids or hot drinks? Hiatal hernia on X-ray? Dysphagia?

4. Root neuritis: had herpes zoster or chest injury? Radiates to radial side of the hand? (Suggests herniated cervical disk.) Cervical root compression syndrome: brought on by arm or head movements?

5. Scalenus anticus or thoracic outlet syndrome: paresthesias and pain along the ulnar distribution? Worse with head turning, abduction, lifting weight, working with hands over the shoulder, or sleeping on side?

6. Costochondritis, myositis, or local neuritis: brought on by local pressure?

7. Fixed output syndrome: known severe aortic or pulmonary stenosis or pulmonary hypertension?

8. Aortic dissection (pain similar to infarction. If in the back, the aneurysm is probably distal to subclavian): pain maximum at onset? Radiates to abdomen or legs? Pain tearing or ripping? Presyncope or syncope with pain? Does it begin in epigastrium and radiate to chest? Has Marfan syndrome or coarctation?

9. Acute infarction (the site either similar to the patient's chronic angina or lower but more widespread): with perspiration, faintness, syncope, nausea, or vomiting? May pace to try for relief.

Note: Epigastric pain with radiation to the neck is almost always due to right coronary disease. Epigastric pain with no radiation means left circumflex disease. Cheat pain radiating down the right arm is usually due to inferior infarction.

10. Aortic stenosis: High velocity jet produces Venturi effect and reduces coronary flow.

Note: The area of the normally open aortic valve is 3-4 cm2. Symptoms usually do not develop until the area is reduced to about a third of normal (1-172 cm2). However, symptoms may not develop until the orifice is only 0.5 cm2.

11. Pulmonary infarction with intercostal tenderness; increases with arm or chest movement.

7. If Patient Says Yes to Palpitations Orientation

When did they begin? Shortest and longest duration, and length of time between episodes?

Types and Rates of Arrhythmias

1. Is beat continuous, or only occasional strong beat? Regular or irregular? (Ask patient to tap out rate and rhythm.) Ever taken own pulse during palpitations? Is ECG abnormal? (Consider Wolff-Parkinson-White syndrome.)

2. Ectopic tachycardia vs sinus tachycardia: does it begin and end suddenly? Occurs at rest or always with exertion? Any maneuvers tried to stop it?


1. Much tea, coffee, cola, or alcohol? On drugs such as digitalis, diuretics, anticho-linergics, or cocaine?

2. Thyroid disease (heat intolerance, etc.; see under High Output Failure Possibilities in Checklist) or pheochromocytoma (flushing, headaches, or perspiration)?

3. Sick sinus syndrome with tachycardia-bradycardia: is there presyncope, syncope, or slow pulse?

8. If Patient Says Yes to Hypertension Orientation

When was patient first told? If treated, for how long? Side effects? Severity

Past blood pressure readings? Had convulsions, strokes, headaches (occipital morning headache suggests severe hypertension), nocturnal dyspnea or dyspnea on exertion, orthopnea, or epistaxis? X-rays and ECG abnormal?


1. Essential hypertension: family history? Onset date? (Essential hypertension usually begins in fourth decade.)

2. Renal: kidney infections or stones, back injury, urinary frequency, polyuria, pros-tatism, gout, or severe diabetes?

3. Coarctation: cold legs, claudication, or shoulder girdle pain?

4. Pheochromocytoma: flushing, pounding headaches, dizziness, perspiration, palpitations, nausea, chest pains, paresthesias, or weight loss?

5. Aldosteronism: episodic or continual weakness, tetany, polyuria (mostly nocturnal), or polydipsia?

6. Hormonal: on contraceptives? Cushing's syndrome: on steroids? Hirsutism, easy bruising, acne, weakness, kidney stones, emotional lability, or depression? Hyperparathyroidism: peptic ulcer (calcium stimulates gastric secretion), renal calculi, constipation, lethargy, or polyuria?



This functional classification (4) refers to fatigue, dyspnea, or angina. The original classification is too long to memorize, and a simplified one follows.

Class 1: The patient is asymptomatic, or symptoms occur on extraordinary exertion. (There is no class 0, or classification for a patient with a normal heart.)

Class 2: Symptoms occur on ordinary exertion.

Class 3: Symptoms occur on less than ordinary exertion.

Class 4: Symptoms occur at rest or on slight exertion.

Note: The functional classification is easily remembered if one simply remembers the words "ordinary exertion," because Class 1 simply adds "extra" in front of ordinary, Class 2 adds no words in front of ordinary, and Class 3 adds "less than" in front of ordinary.


1. Lely, A. H., and vanEnter, C. H. Non-cardiac symptoms of digitalis intoxication. Am. Heart J. 83:149, 1972.

2. Fessel, W. J. High uric acid as an indicator of cardiovascular disease: Independence from obesity. Am. J. Med. 68:3, 1980.

3. Walcott, G., Burchell, H. B., and Brown, A. L., Jr. Primary pulmonary hypertension. Am. J. Med. 49:70, 1970.

4. Criteria Committee, New York Heart Association. Diseases of the Heart and Blood Vessels: Nomencluture and Criteria for Diagnosis (6th ed.). Boston: Little, Brown, 1964, p. 114.

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