Name / age/sex/occupation/address Presenting complaints: History of presenting complaints: 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: 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 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 elabor ate(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) ………………(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:
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
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
Rhythm
Type
Temperature JVP Peripheral signs of AR - signs of wide pulse pressure:
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 ar tery
Local Examination of CVS: Inspection:
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
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 with breath held in expiratory apnea
Aortic: o
First and second heart sounds are heard
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, t he 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
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 /without infective endocarditis complications.
