CASE TAKING PROFORMA - CARDIOVASCULAR SYSTEM

8/11/2019 CASE TAKING PROFORMA - CARDIOVASCULAR SYSTEM

1/7

Name / age/sex/occupation/address

Presenting complaints:

History of presenting complaints:

Chest Pain:

Duration

Site

Mode of onset

Nature

Severity and duration of episode

Radiation

Continuous/intermittent

Brought on by Aggravating / Reliving factors

Associated features - sweating, palpitation

Associated with food intake

Dyspnea:

Duration

Mode of onset

Progression

Grade Aggravating / reliving factors

H/o PND, orthopnea

Associated symptoms - wheeze, cough with expectoration, chest pain

Palpitation:

Duration

Regular / Irregular

Paroxysmal/ not

Brought on by

Aggravating/ Reliving factors

Associated chest pain, syncope

Loss of consciousness:

Episodes/day

Duration

Total/ partial loss of consciousness

Recovery time

Associated fits, bladder/bowel disturbances

Time of last episode


2/7

Cough with expectoration:

Duration

Mode of onset

Quantity

Colour / odour

Postural / Reliving factors

Blood on coughing

o No of episodes

o Colour

o Followed by malena

o Associated with food particles

Negative History:

Symptoms of RHFo H/o pedal edema

o H/o abdominal distension

o H/o dyspepsia

o H/o right hypochondrial pain

o H/o puffiness of face

Symptoms of RF

o H/o fever with pain, sore throat

o H/o involuntary movements

o H/o skin manifestations like rash, nodules

Symptoms of Left sided disease

o H/o voice change, dysphagia

o H/o oliguria

Symptoms of congenital disease

o H/o cyanotic episodes

o H/o squatting

Symptoms of PHT

o Recurrent respiratory infection

o Syncope

o

Hemoptysis(pulmonary apoplexy)o Chest pain

Past History:

H/o previous similar episodes

H/o Rheumatic fever - elaborate(any epistaxis)

H/o HT, DM, TB, IHD, STD, Surgery

H/o chronic respiratory tract infection, cyanotic spells

H/o chronic fever (subacute bacterial endocarditis)


3/7


4/7

Low set ears

Polydactyly

Syndactyly

Arachnodactyly

Amelia, hyomelia Kyphoscoliosis

Webbed neck

Markers of IE

Anemia, jaundice, fever

Oslers nodules, clubbing, splinter haemorrhages - Hand

Jane way lesions

Spleenomegaly

Roths spots(Ophthalmoscopy)

Markers of Rheumatic HD

Markers of Ischemic HD

Markers of syphilis

Alopecia

AR pupil

Retinitis

Gummatous lesions - Tibia, palate, tongue, sternum Septal perforation

Testicular sensation loss

Markers of HIV, TB

Vital signs:

Pulse:

Rate

Rhythm Volume

Character

Felt in all peripheral vessels

Any RF / any PD

Condition of vessel wall

BP

Respiratory rate

Rate


5/7

Rhythm

Type

Temperature

JVP

Peripheral signs of AR - signs of wide pulse pressure:

Lighthouse sign - Alternate flushing and blanching of forehead

Landolfis sign - pupil size varies with each heart beat

Beckers sign - Retinal artery pulsations

Mullers sign - Systolic pulsations of uvula

De Mussets sign - Head bobbing with each heartbeat

Corrigans sign - Dancing carotids

Quinckes sign - Capillary pulsation of nail bed Collapsing pulse

Pulsus bisferans - severe AR

Rosenbachs sign - Pulsation of liver

Gerhardts sign - Pulsation of spleen

Traubes sign - Pistol shot femoral

Hills sign - Popliteal systolic BP > Brachial BP >20 mm

o Mile - 20 - 40

o Moderate - 40 - 60

o Severe - >60

Duroziezs murmur - Double murmur in femoral artery

Local Examination of CVS:

Inspection:

Chest wall symmetry and shape

Kyphoscoliosis

Apical impulse

Tracheal position

Pulsationso Epigastric, hypochondrial

o Parasternal

o Supra & infraclavicular

o Suprasternal, neck

o Interscapular, suprascapular

Precordial bulge

Dilated veins

Signs of surgeries, scars

Drooping of shoulders

Oral cavity


6/7

Palpation:

Apical impulse - site/type/ associated thrill or sound

Epigastric pulsations

Parasternal heave

Thrills over precordium / carotids

Palpable sounds (P2)

Tracheal position

Percussion:

Right border corresponds to right border of sternum

Left border corresponds to apical impulse

Liver dullness is felt in .

Auscultation

Mitral

o First and second heart sounds are heard

o S1 / S2 - loud/normal/soft

o Any S3 or S4

o MDM: A rough rumbling low pitched MDM(of grade) heard with the bell of the

stethoscope with opening snap and PSA (pre systolic attenuation) and the patient

put left lateral position with breath held in expiratory apnea

o PSM: A high pitched, soft blowing PSM (of grade) heard with the diaphragm of the

stethoscope, conducted to the axilla and back, the patient put in left lateral withbreath held in expiratory apnea

Aortic:


o S1/S2 - loud/normal /soft

o Any ejection click

o ESM: A crescendo decrescendo ESM(of grade) heard with the diaphragm of the

stethoscope and conducted to the carotids, the patient leaning forward and breath

held in expiratory apnea

o EDM: A decrescendo pitched EDM( of grade) is heard with diaphragm of the

stethoscope (better heard in the II aortic area say as LT with ICS parasternal) with

the patient leaning forward with breath held in expiratory apnea

Pulmonary:


o S1/S2 - loud/normal/soft

o S2? Split? Narrow/ normal/ wide fixed / reverse

o Any ejection click

o For murmurs

See the aortic area

Say as in inspiratory apnea No conduction as in ESM of AS


7/7

Patient in lying posture

Tricuspid:

o First and second heart sound heard

o S1/S2 - loud/ normal / soft

o Any S3/ S4

Refer mitral area

Say as in inspiratory apnea

MDM: Patient leaning forward

PSM: Patient leaning forward, conduction to right sternum

Other systems:

Respiratory system:

o NVBS

o Basal crepitations

Abdomen:

o Any added sounds

o No organomegaly

o No free fluid

CNS:

o No focal neurological deficit

Diagnosis:

Acquired/congenital heart disease of .(rheumatic) etiology with MS/MR/AS/AR.

The patient is (not)in sound rhythm,../ not in failure.. with /withoutinfective endocarditis complications.

CASE TAKING PROFORMA - CARDIOVASCULAR SYSTEM

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