CVS CASE PROFORMA and Smoking)

Drug intake: H/O Penicillin prophylaxis once in 3 weeks.

Name: Age: Sex: Occupation: Address:
Date and Time of Admission: Date and Time of Examination GENERAL EXAMINATION

HISTORY A __ year old patient, supine decubitus who is ___ built __

nourished is conscious, coherent, cooperative, and
Chief Complaints:
comfortably seated/lying on the bed, well oriented to time,
Chest pain since __ days
place and person.
Shortness of Breath since __ days
Palpitations since ____ days There is No Pallor, Icterus, cyanosis, koilonychias,
Syncope since ____ days generalised lymphadenopathy and no pedal edema.
(Any other complaints if present) Comment on JVO (Raised or not)

History of Present Illness: Grades of Pedal Edema:

Pt was apparently asymptomatic X days back then he 1: Up to Ankle
developed 2:Up to Knee
1. Chest Pain: ___ duration, site, onset, progress, episodes, 3: Full Leg
type, radiation, aggravating and relieving factors, associated 4: Anasarca
night sweats. [Retrosternal, squeezing, radiating to left hand,
jaw, sometimes to right hand] Peripheral Signs of Aortic Regurgitation:
2. Palpitations: At Rest/ Exertion -Quincke’s sign= cyclic reddening and blanching of nail
Duration, onset (persistent/paroxysmal), progress, regularity capillaries
(rapid, slow), orthopnoea, PND, Aggravating and relieving - Collapsing pulse
factors] -Bisferiens pulse= double systolic arterial impulse- twice
3. Breathlessness: Duration, onset, progress, grade, orthopnoea, beating heart
PND, AF and RF -Water Hammer pulse
Grades of Breathlessness: -Lighthouse sign- flushing of forehead
Grade 1: On extremely sever exercise - Corrigan’s pulse= prominent carotid pulsation
Grade 2: On accustomed work - De Musset’s sign on auscultation= Head nodding with each
Grade 3: On routine activity heart beat
Grade 4: At rest -Traube’s sign= Pistol shot sign of femoral artery
4. Syncope: Onset, exercise auscultation
related/circumstantial/positional/neurological - Duroziez’s murmur on auscultation= Femoral artery bruit
5. Cyanosis: Onset, relieving in squatting position - Hill’s sign BP- accentuated leg SBP >40 mmHg different
6. Pedal Edema: Onset, Unilateral/Bilateral, Progression, grade, wrt Brachial artery SBP
pitting/non-pitting, Af and RF, duration. -Becker’s sign= Pulsating retinal arteries
-Lincoln Sign- Pulsatile popliteal
H/O fatigue -Sherman Sign- Prominent dorsalis pedis
H/O cough, haemoptysis ( MS/ Pulmonary Edema) -Muller’s sign- Uvula pulsations with each heart beat
H/O dysphagia, hoarseness of voice in (LAH due to MS) -Landolfi’s sign- Alternating constriction and dilation of
H/O high arched palate, chest deformity – for congenital dx pupils
H/O recurrent respiratory tract infections, fever, sore throat, -Rosenbach’s sign= Pulsating liver
clubbing, splinter haemorrhages- Infective Endocarditis -Gerhardt’s sign= Pulsating spleen
H/O fever, joint pains- Rheumatic Fever
VITALS: Temperature,
SUMMARY: Pulse: Rate, rhythm(regular/irregular), character(normal or
A __ year old male/female patient presented with ___(positive not), volume ( high, normal, low), blood vessel thickening,
findings). peripheral pulsations [Carotid, brachial, radial, femoral,
Anatomical: popliteal, posterior tibial, dorsalis pedis], radio femoral
Etiological: delay or radio radial delay (present or not)
Pathological: The above mentioned positive history is in favour of GIT
system hence I have examined the GIT system in the ____
PAST HISTORY: position
H/O similar complaints in the past BP: 120/80 mm Hg measured on Rt Upper arm In supine
H/O HTN, DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ position
Asthma/COPD/ CAD/ Blood transfusions Respiratory Rate: Thoraco abdominal in females, Abdomino
thoracic in males
FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or SYSTEMIC EXAMINATION-CVS
have had similar complaints or any significant co morbidities

PERSONAL HISTORY:
INSPECTION:
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol
1. Shape of Chest

Syed Murtuza Hashmi, Osmania Medical College

2. Trachea position central or not Any Foreign sounds
3. Any visible precordial bulge(look from end of the bed) Opening snap
4. Visible apex impulse in Lt 5th ICS medial to Mid clavicular Ejection Click
line
5. Any visible left parasternal pulsation – Rt Vent HTN 2. Tricuspid Area:
6. Visible Epigastric pulsations- Aoritc aneurysm Two heart sounds heard, S1 and S2 which are normal
7. Visible 2nd ICS pulsations- Pulmonary Artrery HTN Murmurs same as Mitral area but in lower intensity
8. No other visible pulsations seen
No other scars, sinuses or dilated veins seen in any part of 3. Aortic Area:
the thorax. Two heart sounds are heard, S1 and S2
No bony abnormalities seen (Spine) No murmurs.

4. Pulmonary Area:
PALPITATION: Two HS heard, S1 and S2.
1- All inspector findings were confirmed. S2 is louder than S1.
2-Trachea is central. 5. Erb’s Area- Neo Aortic Area [ 3rd ICS on Lt side]
3-Apex Beat confirmed to be in Lt 5th ICS 1cm medial to MCL
Note: Tapping in character, Localized, Palpable S1,
Corresponding with Carotid pulse, palpable systolic thrill OTHER SYSTEMS:
4-Any palpable heart sounds, suprasternal pulsations CNS- No facial asymmetry, All reflexes are normal
5- Parasternal heave seen in RVH Respiratory: Normal Vesicular Breath sounds, No
6- Any palpable murmurs (thrills) adventitious sounds heard
7- No venous hum at the base of the neck. GIT- No HSM(hepatosplenomegaly), No Ascites
[Venous hum is a benign phenomenon. At rest, 20% of the cardiac output
flows to the brain via the internal carotid and vertebral arteries. This drains
via the internal jugular veins. The flow of blood can cause the vein walls to
DIAGNOSIS:
vibrate creating a humming noise which can be heard by the subject. It is a case of Chronic RHD with MR/MS with or without
Typically, a peculiar humming sound is heard in the upper chest near the congestive heart failure without sings of infective
clavicle. endocarditis in sinus rhythm.
This may be confused with a heart murmur. The venous hum is heard
throughout the cardiac cycle. The difference is easily detected by placing a
finger on the jugular vein when listening to the heart, which will abolish or
change the noise. A true heart murmur will be unaffected by this manoeuvre.
The murmur also disappears when the patient is in the supine position or may
disappear if the subject turns their head to one side. It is also known by the
names "nun's murmur" and "bruit de diable" (the Devil's noise).]

Levine Scale for grading of murmurs:

Grade 1. The murmur is only audible on listening carefully
for some time.
Grade 2. The murmur is faint but immediately audible on
placing the stethoscope on the chest.
Grade 3: A loud murmur readily audible but with no thrill.[4]
Grade 4. A loud murmur with a thrill.
Grade 5: A loud murmur with a thrill. The murmur is so loud
that it is audible with only the rim of the stethoscope
touching the chest.
Grade 6: A loud murmur with a thrill. The murmur is audible
with the stethoscope not touching the chest but lifted just
off it.

PERCUSSION:
1. Rt border of heart corresponds to Rt sternal border
2. Lt border of heart corresponds to apex beat
3. Pulmonary areas resonant on percussion

AUSCULATION:
1. MITRAL Area:
Two Heart sounds heard. S1 and S2. S1 loud, S2 normal
Murmur:
Type- Mid Diastolic/Pan Systolic etc
Character- Low pitch rumbling etc
Radiation
Best heard in Lt Lateral position with bell of the stethoscope
with breath in expiration
Any presystolic attenuation

Syed Murtuza Hashmi, Osmania Medical College