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Clinical Guide
CVS HISTORY TAKING MANUAL
A Comprehensive Clinical Guide for Medical Students and Practitioners
General Communication Skills
Relevant to every step below — don't let running through a checklist in your head become obvious to the patient.
- Empathy: Respond to verbal & non-verbal cues
- Active listening: Body language + verbal acknowledgements
- Eye contact: Appropriate throughout
- Body language: Open, relaxed, professional
- No interrupting: Let patient finish
- Rapport & Signposting: Check in, offer seat, explain what is next
About This Manual
Designed specifically for Cardiovascular OSCE stations (e.g., chest pain, shortness of breath, palpitations).
- Detailed SOCRATES & Cardiac Discriminators
- Red Flag Safety Netting
- Dialogue Scripts included
Prepared by: Dr. Raheel Azhar
1
Opening the Consultation
Wash your hands and don PPE if appropriate. Explain your purpose, then gain explicit consent before continuing.
What to say
"Good morning, I am Dr. [Name], one of the doctors here today. Could I confirm your full name and date of birth, please? I've been asked to take your history today — is that alright with you?"
2
Presenting Complaint (PC)
Give the patient time to answer fully before narrowing down. Use facilitation phrases like: "Can you tell me more about that?" or "Can you explain what that pain was like?"
What to ask
"What's brought you in to see me today?" or "Tell me about the issues you've been experiencing."
Shared Agenda: If there's more than one complaint, negotiate rather than trying to cover everything in equal depth:
"You've mentioned a few issues today. Which one feels most urgent for us to focus on first?"
"You've mentioned a few issues today. Which one feels most urgent for us to focus on first?"
3
History of Presenting Complaint (HPC)
Key Cardiovascular Symptoms to Know:
| Symptom | Clinical Details |
|---|---|
| Chest pain | Central/left-sided (e.g. pericarditis); radiates to left arm/jaw (ACS). Some MI patients present with isolated neck pain. Don't anchor on chest pain alone. |
| Dyspnoea | May be exertional, positional (orthopnoea), or wake the patient from sleep (PND). |
| Palpitations | Fast, fluttering, or pounding, regular/irregular — ask the patient to tap out the rhythm. |
| Syncope | Brief LOC with spontaneous recovery — clarify trigger: postural, exertional, or random. |
| Oedema | Peripheral or central (sacral) — usually heart failure or medication side effect (e.g., amlodipine). |
| Intermittent Claudication | Calf pain on mild exertion, relieved by rest — suggests peripheral vascular disease. |
| Systemic | Fatigue (heart failure), fever (pericarditis/endocarditis), weight loss/gain. |
A. If Pain Is the Complaint -> Use SOCRATES
- Site: "Can you show me exactly where the pain is?"
- Onset: "When did it start? Sudden or gradual? What were you doing?"
- Character: "How would you describe it — sharp, dull, burning, crushing?"
- Radiation: "Does it spread anywhere — your arm, jaw, back, or neck?"
- Associated symptoms: "Noticed anything else — sweating, feeling sick, breathless?"
- Time course: "How has it changed over time?"
- Exacerbating/relieving: "What makes it worse (exertion)? What helps (rest, GTN)?"
- Severity: "On a scale of 0–10, how bad is it?" Ask about performance status (walking distance).
Directly Probe Cardiac Discriminators
These carry diagnostic weight on their own, so don't accept a single yes/no:
- Orthopnoea/PND: "Do you wake up gasping for breath, or need extra pillows to sleep comfortably?" (Quantify pillows)
- Oedema: "Any swelling in your ankles or legs?"
- Palpitations: "Does your heart ever race, flutter, or skip? Could you tap out the rhythm for me?"
- Syncope: "Any fainting or near-fainting spells? What were you doing just before?"
Non-pain presentations: SOCRATES is for pain. If the presenting complaint is non-pain (breathlessness, palpitations, oedema), switch to Structured Symptom Analysis instead — Onset, Course/Duration, Severity/Quantity, Character, Associated Symptoms, Exacerbating/Relieving. Never force a non-pain symptom into the SOCRATES frame.
4
Ideas, Concerns, and Expectations (ICE)
Weave this in naturally in response to cues, rather than as a rigid block.
What to ask & Signposting
Ideas: "What do you think the problem is?"Concerns: "Is there anything in particular that's worrying you? What's the worst thing you were thinking it might be?"
Expectations: "What were you hoping I'd be able to do for you today?"
Signposting: "So we've talked about your symptoms, your concerns, and what you're hoping we achieve today. Next I'd like to screen for a few other symptoms, then ask about your medical history."
5
Past Medical History (PMH)
Cardiovascular Risk Factors to Identify: Hypertension, Hyperlipidaemia, Diabetes.
Other relevant conditions to have in mind: angina, MI, heart failure, obesity, chronic kidney disease, atrial fibrillation, stroke, peripheral vascular disease, rheumatic fever.
What to ask
"Do you have any medical conditions? Are you seeing a doctor or specialist regularly?" (If yes, ask how well controlled it is and about complications)."Have you previously had any operations or procedures — for example a stent, bypass, valve replacement, or pacemaker? When, and why?"
6
Allergies
What to ask
"Do you have any allergies? What exactly happens when you have a reaction?"
7
Drug History
Document name, dose, frequency, form, route. Ask specifically: "Have you noticed any side effects?"
| Class | Commonly Used For |
|---|---|
| Beta-blockers | AF, coronary artery disease, heart failure |
| Calcium channel blockers | Hypertension |
| ACE inhibitors | Hypertension, heart failure |
| Diuretics / MRAs / SGLT-2i | Heart failure |
| Statins / Antiplatelets | Coronary artery disease |
| Anticoagulants | AF, artificial heart valve |
| GTN spray | Angina |
OTC Drugs Warning: Ask specifically about NSAIDs (worsen heart failure, raise MI risk) and St John's Wort (lowers warfarin's effect). Patients rarely mention these unprompted.
What to ask
"Are you currently taking any prescribed medications or over-the-counter treatments?"
8
Family History
Cardiovascular Risk Factor to Identify: Family history of cardiac disease.
Ask about age of onset — this matters more than the condition alone. Unexplained sudden death in a young relative raises suspicion for inherited channelopathies (Brugada, long QT).
What to ask
"Do any of your parents or siblings have heart problems?""At what age did your father have his heart attack?" / "When was your mother diagnosed with high blood pressure?"
(If relative deceased): "I'm sorry to hear that — do you mind me asking how old he was, and what was felt to have caused it?"
9
Social History
Cardiovascular Risk Factor to Identify: Smoking.
- Smoking: Type/amount. Calculate pack-years. Ask about vaping.
- General Context: Accommodation, adaptations (stairlift), support network, carer input.
- Alcohol: Frequency, type, and volume per week.
- Diet & Exercise: High salt/saturated fat? Frequency of exercise?
- Occupation & Driving: Activity level. Advise against driving if syncope is present until cleared (inform DVLA).
- Gambling: "Do you gamble at all? Does it ever feel like a problem?" (Linked to poor sleep, anxiety, substance misuse).
| Recreational Drug | Cardiovascular Effect |
|---|---|
| Cocaine, ecstasy, amphetamines | Sympathetic activation: tachycardia, BP swings, coronary vasospasm |
| Opiates (morphine, heroin) | Parasympathetic activation: bradyarrhythmia, hypotension, syncope |
| Cannabis | Sympathetic at low dose, parasympathetic at high dose |
| IV drug use (any) | Predisposes to bacterial endocarditis |
10
Systemic Review
Screen briefly across other systems — this can surface symptoms the patient forgot to mention.
| System | Screen for |
|---|---|
| General | Fevers, weight change, fatigue |
| Respiratory | Dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic pain |
| Gastrointestinal | Dyspepsia, nausea, vomiting, dysphagia, abdominal pain |
| Genitourinary / Neuro | Oliguria, polyuria / Visual changes, motor/sensory disturbance |
| MSK / Derm | Chest wall pain, trauma / Rashes, ulcers |
11
Summary
Summarise the key points back to the patient. Continue summarising periodically rather than saving it all for the end. Ask if there's anything you've overlooked.
What to say
"To summarise, you're a [age]-year-old presenting with [symptom/onset/character], associated with [key discriminators], on a background of [key risk factors]. Does that sound accurate?"
12
Safety Netting & Follow-up
Thank the patient for their time. Dispose of PPE appropriately and wash your hands after communicating the safety net.
What to say
"If your symptoms get significantly worse, or you develop [specific red flag — e.g. pain unrelieved by rest, fainting, worsening breathlessness], please seek immediate medical attention — call an ambulance or go to your nearest A&E, don't wait. If there's no improvement, please book a follow-up with us."
History-Taking Flow
01 Opening
02 PC
03 HPC (SOCRATES)
04 ICE
05 PMH
06 Allergies
07 Drug Hx
08 Family Hx
09 Social Hx
10 Systemic Review
11 Summary
12 Safety Netting
OSCE Pacing Challenge: CVS Red Flag Injections
Read the clinical vignette, verbalize your "must-not-miss" red flag questions out loud, and then click to reveal.
Scenario 1: "A 45-year-old man presents with sudden, tearing chest pain radiating through to his back, occurring at rest, with unequal blood pressures in each arm."
- Aortic Dissection check: "Did the pain reach maximum intensity immediately, and does it feel like tearing rather than crushing?"
- Risk factors check: "Any history of Marfan syndrome, bicuspid aortic valve, or poorly controlled hypertension?"
Scenario 2: "A 30-year-old woman, two weeks post-caesarean section, presents with sudden pleuritic chest pain and breathlessness, with a swollen, tender right calf."
- Pulmonary Embolism check: "Is the pain worse on deep inspiration, and did the breathlessness come on suddenly?"
- DVT check: "Any recent immobility, surgery, leg swelling, or long-haul travel?"
Scenario 3: "A 60-year-old man with a history of rheumatic fever as a child presents with fevers, night sweats, and new-onset shortness of breath over several weeks, plus a new heart murmur."
- Infective Endocarditis risk check: "Any recent dental work, IV drug use, or indwelling lines/catheters?"
- Embolic phenomena check: "Any new skin lesions, joint pains, or splinter haemorrhages under the nails?"
References:
• Bates' Guide to Physical Examination and History Taking (12th ed.)
• Macleod's Clinical Examination (15th ed.)
• NICE Guideline NG185: Acute coronary syndromes
• ESC/AHA Guidelines for ACS and Heart Failure
• Bates' Guide to Physical Examination and History Taking (12th ed.)
• Macleod's Clinical Examination (15th ed.)
• NICE Guideline NG185: Acute coronary syndromes
• ESC/AHA Guidelines for ACS and Heart Failure
Live Session Score
0 / 16
History-Taking Flow
01 Opening
02 PC
03 HPC (SOCRATES)
04 ICE
05 PMH
06 Allergies
07 Drug Hx
08 Family Hx
09 Social Hx
10 Systemic Review
11 Summary
12 Safety Netting
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