Case Taking Proforma - Cardiovascular System 2g4w5n

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

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: 

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Symptoms of RHF o 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)

Family History:   

Elaborate H/o HT, DM H/o abortions in female

Personal History:     

Smoking Alcohol Diet Sexual History Menstrual History

Treatment History: Summary: Age/sex/name? Personal History? Family history? PC  

Other relevant positive features Probable system? CVS

The disease is probably ………………..(cong/acq). Probably a ………………(recurrent) heart disease involving the ……………(lt/rt/both) side(s), the probable valve(s) involved are …………………… The patient shows the signs/symptoms of ………………………….(LVF/RVF/CCF) Examination of CVS case: General examination:           

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Conscious Comfortable Oriented Build Nourishment Febrile/ afebrile Jaundiced/not Pallor Clubbing - grade Cyanosis Pedal edema with refilling time o Rapid - renal < 45 secs o Slow - CCF Significant lymphadenopathy

Markers of Congenital HD 

Hypertension

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Low set ears Polydactyly Syndactyly Arachnodactyly Amelia, hyomelia Kyphoscoliosis Webbed neck

Markers of IE     

Anemia, jaundice, fever Osler’s nodules, clubbing, splinter haemorrhages - Hand Jane way lesions Spleenomegaly Roth’s 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

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Rhythm Type

Temperature JVP Peripheral signs of AR - signs of wide pulse pressure:             

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Lighthouse sign - Alternate flushing and blanching of forehead Landolfi’s sign - pupil size varies with each heart beat Becker’s sign - Retinal artery pulsations Muller’s sign - Systolic pulsations of uvula De Musset’s sign - Head bobbing with each heartbeat Corrigan’s sign - Dancing carotids Quincke’s sign - Capillary pulsation of nail bed Collapsing pulse Pulsus bisferans - severe AR Rosenbach’s sign - Pulsation of liver Gerhardt’s sign - Pulsation of spleen Traube’s sign - Pistol shot femoral Hill’s sign - Popliteal systolic BP > Brachial BP >20 mm o Mile - 20 - 40 o Moderate - 40 - 60 o Severe - >60 Duroziez’s murmur - Double murmur in femoral artery

Local Examination of CVS: Inspection:     

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Chest wall symmetry and shape Kyphoscoliosis Apical impulse Tracheal position Pulsations o 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

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 o o o

o

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Aortic: o o o o

First and second heart sounds are heard S1 / S2 - loud/normal/soft Any S3 or S4 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 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 with breath held in expiratory apnea

First and second heart sounds are heard S1/S2 - loud/normal /soft Any ejection click 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 First and second heart sounds are heard 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

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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: 

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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 /without infective endocarditis complications.