HISTORY TAKING: CARDIOVASCULAR HISTORY 1
Introduction

Your name is Simon Carter and you are a 52-year-old man.
Presenting complaint

You have come to see the PA in your local general practice today because you have been experiencing
episodes of chest pain.
History of presenting complaint

When it occurs, it feels like a crushing pain in the centre of your chest, a bit like a heavy object is resting on it.
It sometimes feels a little like the pain moves into your left arm.

The pain last came on yesterday after you climbed a hill in the park. You rested on a bench and the pain
stopped after 5 to 10 minutes. When it first came on, you felt a bit cold and sweaty but that went off with
time as well. Yesterday, the pain was quite severe. If someone asked you to grade it out of ten, it would have
been a seven.

This isn’t the first time that you have experienced this pain. It has happened 3 or 4 times before, but it was
never as bad as it was yesterday; before the severity would have been four out of ten. One time when it
happened, you were digging in the garden and had to sit down and rest. Another time, you had just climbed
two flights of stairs in the multi-storey car park. It went off again after a couple of minutes.
Past medical history

You’ve always considered yourself to be healthy and you hardly ever go to see the doctor. You’ve never had
to stay in hospital in the past.
Drug history

During a routine check-up four years ago, the GP said you had high blood pressure and started you on a
medication called Ramipril, which you take daily

You use a skin cream that you buy over the counter for a dry rash you get on your elbows

You are not allergic to any medications
Family history

You are an only child. Your mum is alive and well but your dad passed away following a heart attack at the age
of 62.
Social history

You live with your wife, who is fit and well and have a 20-year-old daughter who is at university. You
work part-time as a management consultant. You semi-retired 6 months ago as you were struggling
with stress. You were finding it hard to sleep and often felt anxious.

You used to exercise regularly, but you are not able to do as much nowadays because you become
breathless quite easily. You have smoked 20 cigarettes a day since you were 18 years old. You have
tried to give up a couple of times but you have never succeeded. You meet up with you friends at
the pub twice a week. Each time you drink about 5 pints of bitter. You enjoy quite a traditional diet,
with meat and vegetables. You don’t eat many takeaways or ready meals, but you like your puddings.

You have not been abroad recently.
MSC PHYSICIAN ASSOCIATE STUDIES
CLINICAL AND PROFESSIONAL SKILLS
Ideas, concerns and expectations

You have come to the GP today because you are worried that there might be a problem with your heart.

You are worried because your dad was only ten years older than you when he died.

You want to know if there are any medications that you might be able to take to stop these episodes of pain.
Deep down, you know that you should cut down on the cigarettes and alcohol.
MSC PHYSICIAN ASSOCIATE STUDIES
CLINICAL AND PROFESSIONAL SKILLS