GENERAL MEDICINE - UG

CASE PROFORMA – CARDIOVASCULAR SYSTEM

CASE SHET FORMAT

HISTORY TAKING

Name:
Age:
Sex:
Residence:
Occupation:

Chief complaints (describe in chronological order):

1. -x days
2.x days
3.x days

Dyspnea:
• Duration
• Onset
• Progression
• Aggravating factors
• Relieving factors
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Associated symptoms-Wheeze;Cough with expectoration

Chest pain:
• Duration
• Onset
• Site
• Type of pain
• Radiation
• Diurnal variation (nocturnal angina)
• Aggravating factors
• Relieving factors
Associated symptoms- Nausea, vomiting, sweating
• Dyspepsia
• Local tenderness
Angina equivalents. - Dyspnea ,Diaphoresis,Discomfort in lower jaw,Dyspeptic symptoms Fatigue

Palpitations:
• Duration
• Precipitating factors /Persistent / paroxysmal
Pedal edema:
• Duration
• Onset
• Progression
• Relieving factors
• Is it preceded by facial puffiness or followed by facial puffiness?
• Diurnal variation or decreased in supine position

• Any Other symptoms:

Past history:
History of any similar complaints in the past
• Chronic obstructive airway disease
• Diabetes mellitus
• Hypertension
• Ischemic heart disease IHD)
• Rheumatic fever

Family history: any similar complaints in family / h/o cardiac diseases or sudden cardiac death

Personal history:
• Smoking Index or Pack years
• Alcohol history (if yes mention in grams of alcohol)
• Sleep

Treatment history:
• Drugs using
• Any intramuscular injections (once in 3 weeks IM injection most likely to be benzathine
penicillin for rheumatic heart disease prophylaxis)

Menstrual and obstetric history:

• Gravida, parity, live births, abortions (GPLA)
• Age of menarche
• Menopause at
• Duration

Summarize: if breathlessness is present then NYHA grading should be mentioned

 GENERAL EXAMINATION

Patient is conscious/not

Oriented/not

Comfortable/not

Co-operative/not

Built

Signs of nutritional deficiency

Febrile/afebrile

Palor

Icterus

Cyanosis-central/peripheral

Clubbing – bilateral/unilateral, pandigital/limited

Pedal edema – bilateral/unilateral, painless/painful, pitting(soft/hard)/non-pitting, extension,

regional lymphadenopathy

Significant lymphadenopathy

MARKERS OF RHEUMATIC FEVER - migratory polyarthritis, erythema marginatum,

subcutaneous nodules, sydenham’s chorea

MARKERS OF INFECTIVE ENDOCARDITIS - anemia, fever, jaundice, splinter

haemorrhages, clubbing, splenomegaly, arthritis, osler’s nodes, janeway lesions

MARKERS OF ATHEROCLEROSIS - arcus senilis, xanthelasma, ear lobe creases, obesity,

nicotine staining, xanthomas

MARFANOID HABITUS

high arched palate, thumb sign, wrist sign, arm span/height ratio, upper segment/lower segment
ratio
VITAL SIGNS

PULSE: rate, rhythm, volume, character, felt in all accessible peripheral pulses/not, radioradial/
radiofemoral delay, apex pulse deficit, condition of vessel wall.

BLOOD PRESSURE: _____mm of Hg measured in the Left Upper limb in the sitting position and
______mm of Hg measured in the Left Lower limb with the patient in the prone position.

RESPIRATORY RATE: _____/min, regular/not, type- thoraco abdominal/abdomino thoraxic

TEMPERATURE: _______F measured in the axilla

JVP:

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

INSPECTION:

Chest wall shape and symmetry/ pectus excavatum / pectus carinatum / precordial bulge/
kyphoscoliosis

Apical impulse

Pulsations – epigastric, parasternal, pulmonary, aortic, suprasternal, supraclavicular, infraclavicular,

suprascapular, interscapular.

Dilated veins, scars, sinuses

PALPATION:

Apical impulse – normal/absent/tapping/heaving/hyperdynamic

Pulsations – Epigastric pulsations,

Parasternal Heave – Grading,

Palpable Pulmonary valve closure,

Thrills – Precordial/Carotid thrill

AUSCULTATION:

1. MITRAL AREA:

S1, S2,

MITRAL CLICKS

MDM: A low pitched, rough rumbling mid diastolic murmur of Grade ___ is heard with the bell of
the stethoscope with opening snap and presystolic accentuation with the patient lying down in the
left lateral position with the breath held in expiration

PSM or HSM: A high pitched, soft blowing holo systolic murmur of grade___ is heard with the
diaphragm of the stethoscope conducted to the axilla and the back or base with the patient lying
down in the left lateral position with the breath held in expiration

2. TRICUSPID AREA:

S1, S2,

3. PULMONARY AREA:

S1, S2, S2 SPLIT, P2 LOUD,

PULMONARY EJECTION CLICK

[Link] AREA:

S1, S2

EJECTION CLICK

ESM: A high pitched, crescendo decrescendo ejection systolic murmur of Grade ___is heard with
the diaphragm of the stethoscope conducted to the carotids with the patient in the sitting position
with the breath held in expiration

EDM: A high pitched, soft blowing Early Diastolic Murmur of Grade___ is heard with the
diaphragm of the stethoscope better heard in the Second Aortic Area with the patient in sitting
position leaning forward with the breath held in expiration

SECOND AORTIC AREA(ERB’S AREA)

INFRACLAVICULAR AREA (GIBSON’S AREA)

 EXAMINATION OF OTHER SYSTEMS

RESPIRATORY SYSTEM:

ABDOMEN:

NERVOUS SYSTEM:

DIAGNOSIS

ACQUIRED VALVULAR HEART DISEASE OF PROBABLE RHEUMATIC ETIOLOGY

________WITH PULMONARY HYPERTENSION AND ATRIAL FIBRILLATION WITH
EVIDENCE OF CONGESTIVE HEART FAILURE WITH/WITHOUT SIGNS OF ACTIVE
RHEUMATIC FEVER AND INFECTIVE ENDOCARDITIS.
 CVS DEMONSTRATION..

1. Pallor.

2. Icterus.

3. Pedal edema.

4. Clubbing

5. Externalmarkersofmarfanssyndrome.

6. Examinationofvallaccessibleperipheralpulses.

7. Pulses deficit

8. Collapsing pulse.

9. Measurement of P

[Link] of JVP.

[Link]

[Link] between arterial and venous pulse.

c. Hepatajugular reflex.

11. Apical impulse location.

[Link] areas..
CVS QUESTIONS..

1. What are all the cardinal symptoms of CVS.?

2. Define palpitations.

3. Define angina equivalents.

4. Clinical features and pathophysiology of PND.

5. Clinical features and pathophysiology of orthopnea.

6. NYHA GRADING .

7. JONES CRITERIA.

8. CVS causes of clubbing.

9. External markers of infective endocarditis.

10. External markers of congenital heart disease

11. External markers of atherosclerosis.

12. What is pulse deficit?

13. What is pulse pressure?

14. What is pulsus parvus et tardus?

15. What is pulus bisferiens?

16. What is collapsing pulse?

17. What is pulsus alternans?

18. How do you measure JVP?

19. Draw jvp waveform and describe each positive and negative wave.

20. How will you differentiate venous pulse from arterial pulse over the neck?

21. Describe HEPATO JUGULAR REFLEX.

22. Define apical impulse.

23. Normal and abnormal position of apical impulse .

24. Types / character of apical impulse?

25. What is parasternal heave? How will you grade?

26. What is the significance of palapable P2?

27. How do you differentiate systolic and diastolic trill?

28. What are all the auscultatory areas of the CVS?

29. Why there is a Loud s1 in MS.?

30. Inference Loud P2?

31. What is opening snap(os) in MS?

32. What is the significance of precordial bulge?

33. Describe MDM.

34. Describe PSM.

35. Describe ESM.

36. How will you assess the severity of MS clinically?

37. Causes of MDM.

38. Difference between functional murmur and organic murmur.

39. What is silent MS?

40. Clinical Signs of pulmonary hypertension.

41. Define JVP.

42. What are all the low pitched sound in cvs?

43. Grades of murmur.

44. Difference between A2OS and A2P2.

45. What is AUSTIN FLINT MURMUR?

46. Define cannon waves?

47. Significance of S3,and S4?

48. Difference between pressure overload and volume overload of left ventricle.

49. What is continuous murmur?

50. What is TO and FRO murmur?.

 MITRAL REGURGITATION

A 34-year-old male presented with dyspnea on exertion,

palpitations and leg swelling.

Examination
Vitals: Pulse rate-76/min ,irregularly irregular with variable
volume
Bilateral pitting type of pedal edema present in both lower
limbs

Apex beat-felt in the left 6th ICS, 2.5 cm lateral to MCL,

hyperdynamic in character
Parasternal heave present
Mitral area-
S1 variable and diminished
Mid-diastolic murmur of Grade 3 best heard in left lateral
position in expiration with bell of stethoscope
Pansystolic murmur of Grade 3, radiating to left axilla
Opening snap-not heard

Write a Casesheet with the above mentioned

findings and substantiate your Diagnosis.
 MITRAL STENOSIS

A 34 year old female with no known comorbidites,was brought with

the complaints of gradually progressive breathlessness for 6
months,now breathless even at rest and c/o palpitations for 1 month
and easy fatiguability for 1 month with bilateral swelling of legs and
also c/o hemoptysis for 1 week. Following are the important findings :

Examination:
B/L Pitting Pedal Edema +
Pulse : Irregularly Irregular
JVP: Elevated 5cms of water
CVS :
Epigastric pulsations +
Left Parasternal Heave Grade 2
Mitral Area : Tapping S1, Diastolic murmur +,Thrill +
Aortic area :Normal
Pulmonary area :Loud and palpable P2 +
Tricuspid Area : S1S2 +
Other Systems : Abdomen :Hepatomegaly +
RS : Normal
CNS :Normal
Write a Casesheet with the above mentioned findings and
substantiate your Diagnosis.
 AORTIC STENOSIS

A 62 year old male ,a known case of Systemic Hypertension

for 10 years, was brought with the complaints of gradually
progressive ,exertional breathlessness for 6 months, now
unable to climb stairs and c/o exertional chest pain for 1 month
and one episode of loss of consciousness 1 week
[Link] are the important findings :

Examination:
Pulse : low volume
CVS :
Mitral Area : S1S2+, Heaving Apical Impulse,S4 +
Aortic area : S1S2+, Ejection Systolic Murmur +, Thrill+,
Single S2 +,
Carotid Shudder +
Pulmonary area :S1S2+,
Tricuspid Area : S1S2 +
Other Systems : Abdomen :Normal
RS : Normal
CNS :Normal
Write a Casesheet with the above mentioned findings and
substantiate your Diagnosis.