CARDIOVASCULAR SYSTEM

1. Bio data
Name:
Age:
Sex:
Address:
Occupation:
Religion:
SES:

2. Presenting complaints

1. Dyspnoea
2. Orthopnoea
3. PND(Paroxysmal nocturnal dyspnoea)
4. Palpitations
5. Syncopal attacks
6. Facial puffiness & swelling of feet
7. Haemoptysis
8. Cyanosis
9. Chest pain
10. Fever
11. Joint pain
12. Arthritis
13. Rash
14. Embolic events
15. Any drug history

3. H/O present Illness

a. Dyspnoea –
 Onset – sudden/ recurrent
 Duration
 Grading
 b. Haemoptysis –
 present or not, if present duration

4. H/O past illness:

 Any history suggestive of Rheumatic fever
 Any Similar complaints in past
 Any H/O DM, Tb, HTN, Epilepsy, Asthma and any
Ch. Diseases
 H/O of any Exhanthamatous farers

5. Family History:
 Any similar complaints in the family members
 Any H/O DM, Tb, HTN, Epilepsy, Asthma and any
Ch. Diseases

6. Personal History:
 Diet
 Sleep
 Addictions
 B&B
 Exposure to STD’s

7. Mensural History(if FEMALE):

 Age of Menarche
 Cycle
 Amount of Bleeding
 Menopause

8. Marital History :

 Age of Marriage
 Age of conception
 Age of 1st child
 Age of last child
 History of breast feeding
 9. General Exam:

Patient is conscious, coherent, co-operative and well oriented

to time, place, person

I. Built and Nutrition

II. Thyroid
III. Body hair distribution
IV. Secondary sexual characters
V. Hyper/Hypo pigmented patches

VI. VITALS(should be written completely

 Pulse:
 Rate
 rhythm,
 volume
 vessel wall thickening
 any special character
 radio radial & radio femoral delay
 other pulses
 BP
 RR
 Temp

VII. PICKLE

10. SYSTEMIC Exam:

A. Neck
i. JVP
ii. Carotid pulsations
iii. Central venous pressure
iv. Supraclavicular pulsations
v. Supra sternal pulsations
vi. Thyroid swelling
 B. CHEST & Precordium:
i. Inspection:

a. Shape
b. Symmetry
c. Precordial bulge if any
d. Apical impulse
e. Parasternal heave
f. Any other pulsations(Epigastric)
ii. Palpation:

a. Apex:
 Apex beat—normal/Heaving/Tapping/Diffuse down and out

b. Palpable heart sounds—present/absent

c. Palpable added sounds
d. Thrill
e. Pericardial rub

iii. Percussion:
a. Generalized percussion to outline the
Cardiac borders
iv. Auscultation:
Areas of AUSCULTATION

1. Mitral area: Near apex

2. Tricuspid area: 5th ICS

Parasternal line

3. Pulmonary area: Lt. 2nd ICS

4. Aortic area: RT. 2nd ICS

5. Neo aortic area: LT. 3rd ICS

6. LLSB: Left lower sternal border

Normal Heart sounds
1. 1st heart sound(S1)
 Components M1 & T1
2. 2nd heart sound(S2)
 Components A2 & P2
M, T, A, P: They represent sounds
arising due to respective valve
closure
Added sounds
1. 3rd heart sound GALLOP
2. 4th heart sound
3. Murmurs
 Ejection systolic murmur (ESM)
 PAN systolic murmur (PSM)
 Early diastolic murmur (EDM)
 Mid diastolic murmur (MDM)
 Delayed diastolic murmur
 CONTINUOUS murmur
4. Ejection click
5. Opening snap
6. Pericardial rub

1. S1 & S2 Audible S1 better audible

2. Rough & rumbling MDM(low pitch) – MS
MITRAL Area 3. Soft & blowing PSM – MR
4. AUSTIN FIELD murmur (MDM)—Severe AR
5. Opening snap – MS
6. Ejection click – AS
7. Pericardial rub – Rheumatic heart disease(RHD)
1. S1 & S2 Audible S1 better audible
TRICUSPID Area 2. PSM – TR

1. S1 & S2 Audible S2 better audible

PULMONARY 2. Loud P2 – MS
Area 3. Loud P2 + Short ESM + Parasternal Lift – Pul.HTN

1. S1 & S2 Audible S2 better audible

AORTIC Area 2. Rough low pitched ESM Cresendo-decresendo type –
AS

LLSB PSM, DDM, Masked S1,S2 – VSD

Neo aortic area 1. EDM – AR

11. Other Systemic examination:
Respiratory
CVS
CNS

12. PD (Provisional Diagnosis):

13. D/D:

a. Rheumatic Fever
b. Mitral stenosis
c. Mitral regurgitation
d. Aortic stenosis
e. Aortic regurgitation
f. Pulmonary stenosis & regurgitation
g. Tricuspid stenosis & Regurgitation
h. ASD, VSD, PDA, T.O.Fallot
MS 1. Sob
2. Cough
3. Haemoptysis
4. PND
5. Acute Pul.Oedema with ascites
6. Atypical angina
7. Pulse—irregular, low volume
8. RR—increased
9. JVP – Increased ‘a’ wave seen
10. Apex – Tapping with diastolic thrill, Parasternal impulse present
11. S2 – Palpable, split with loud p2

MR 1. Fatigue
2. Dyspnoea
3. Pul.Congestion(Creppetations)
4. Pulse – increased resting pulse, Water hammer pulse
5. RR – Increased
6. Apex – Diastolic thrill present
7. S1 – Soft
8. S2 – Widely Split
9. S3 – Gallop present
10. PSM
11. DDM Radiating to Axilla & back
AS

AR

JVP Carotid Pulse

1. Better seen 1. Better Felt
2. Multiple waves 2. Single Wave
3. Resp. & Variation present 3. NO Variation
PULSE
Irregular Pulse 1. A. Fibrillations
2. Sinus arrhythmias
3. Multiple ventricular ectopic
4. A.Fib with varying block
5. SVT. With varying block
Volume Diff. Between SBP & DBP
(Pulse Pressure) 1. Normal – 40
2. >40 – High volume
3. <40 – Low volume

Pulses rarus 1. 1o heart block

(Brady cardia) 2. β-Blockers
3. Obstructive jaundice
4. Hypothyroid
5. 1st wk. of typhoid
Pulses Frequencus 1. Heart failure
(Tachy cardia) 2. Hyper dynamic circulatory states

Special character 1. Water hammer pulse – AR

2. Pulses paradox us – Cardiac tamponade
3. Pulses alterance – CCF, Pul.Embolism,
Myocarditis, Tamponade, As, Cardiomyopathy
4. Collapsing Pulse – AR,MR
5. Pulses Tardus – Severe AS & MS
6. Pulses Bisference – AR, AR with cardiomyopathy
7. Pulses Bigemini – Shock, Cardiomyopathy
8. Dichroitic pulse – AS, MS, Card.Myo.
9. Absent pulse – TAKAYASU disease
Delay 1. Radio-radial delay – Supra aortic stenosis
2. Radio-femoral delay – Coarctation of aorta

Other Pulses 1. Carotid

2. Brachial
3. Radial
4. Femoral
5. Popliteal
6. Post. Tibial encircling medial
7. Dorsalis Pedi’s
Apex Beat:
I. Seen or felt in Lt. 5th ICS ½ inch Medial to mid clavicular
line
II. Not more than 1 inch diameter
III. Not more than 1ICS
IV. Perpendicular thrust for Initial 1/3rd of systole

Parasternal Heave:

I. G1 – Pulsation +, Lift –
II. G2 – Pulsations+, Lift+ can be obliterated
III. G3 – Pulsations +, Lift + can’t be obliterated

PALPITATIONS:

I. Unpleasant awareness of once own heart beat

II. Due to
 Arrhythmias
 Tachycardia
 Valvular heart diseases (AR & MR)

Orthopnoea:

I. Dyspnoea on lying down position

II. relieved on sitting position
III. seen in LVF

Fever:
I. seen in
 IE
 RF
 Pericardial effusion
 Acute MI

Oedema:
 II. Initial stages B/L pedal oedema
III. Later Anasarca seen in
 CHF
 Nephrotic Syndrome
 Wet beriberi
 Hypoproteinaemia due to any cause

PND:
I. Occurs during sound sleep of >2-3hrs
II. Due to
 Decreased adrenergic drive
 Increased venous return to heart
 Elevated position of diaphragm
III. Relived on standing & walking for some distance

Dyspnoea
Grading (NYHA)

G1 – uncompromised & no limitation to physical activity

G2 –Slightly compromised with slight limitation of activity
discomfort with normal activity
G3 – Markedly compromised with marked limitation of
activity discomfort with less than normal activity
G4 – severely compromised with discomfort even at rest