Case Sheet:

Cardiovascular System
HISTORY TAKING:-

NAME:

AGE:

GENDER:

ADDRESS:

OCCUPATION:

Chief complaints and Duration: (To be described in patients own words)

To be in chronological order

History of present Illness:

Each and every complaint needs to be analysed systematically (Symptom Analysis)

CHEST PAIN:

Duration; Onset; Site; Type or Character (Pricking, Burning, Dull aching etc); Continuous or Intermittent;
Aggravating Factors; Relieving factors; Radiation of the pain; Associated features like sweating,
palpitation and any other points.

BREATHLESNESS:

First confirm it is actually breathlessness; Duration; Onset ...how it started (sudden, gradual) and
Progress (same grade throughout or improving or worsening); then Grade it. Grade 1 to 4 as per NYHA
criteria; Aggravating Factors; Relieving factors; Orthopnea and Paroxysmal Nocturnal Dyspnoea;
Platypnea and Trepopnea; associated symptoms like bluish discolouration

OEDEMA:
Onset; unilateral or bilateral; where it started first....puffiness of face or pedal odema or ascites
etc..pitting or non pitting; Duration; Progress; Associated with pain or not; associated symptoms like
reduced urine output ..

Palpitation:

First confirm it is actually palpitation; Onset; how it started (sudden, gradual); Duration and how it
is progressing ( same severity throughout or improving or worsening); associated symptoms like
giddibness and chest pain..

Other cardiac symptoms like Syncope, Dizziness etc

Ask leading questions related to other systems; even if the patients did not tell about the symptoms
related to other systems, you have to put leading questions; like “do you have cough?” etc...Only main
symptoms.

Past History:

Similar illness in the past (whether the patient had same symptoms in the past)

History suggestive of Rheumatic fever (History of sore throat, Joint pain, involuntary movements etc...
Past events of Chest pain, Breathlessness, Palpitation; if present treatment taken for the symptoms;
whether patient felt better with treatment; details of treatment; about drugs, procedures, surgeries,
dietary advice etc.

History of Hypertension, Diabetes Mellitus, Tuberculosis, Dyslipidemia etc.

PERSONAL HISTORY:

Diet: Vegetarian/ Non vegetarian (actually we need to ask their full diet, because the term Vegetarian/
Non vegetarian may not give us the correct details.

Exercise:

Lifestyle:

Smoking: How long; How many cigarettes or beedies or other types;

Alcohol: How much and how long?; type of alcoholic beverage? etc

Chewing : TOBACCO /PAWN/Betel Nut etc

Drugs: Oral or Intravenous, Type of drugs?

Sensitive and Sexual History:

History of exposure to sexually Transmitted Diseases; Extra Marital relationships, Intra Venous drug use
etc.
Family History:

o About the patient, his parents, his children if married

o Married or not:

o If married, Time since marriage?

o Consanguinity; Number of children; other relevant details.

If possible, draw the Family Tree

Family history of Hypertension, Diabetes Mellitus, Tuberculosis, Dyslipidemia, Congenital illnesses etc.

Menstrual/Obstetrical/Gynaecological History:

o Menarche; if yes, at what age it is attained?

o Menstrual Cycles - REGULAR/IRREGULAR, FLOW, FREQUENCY, ASSOCIATED PAINS

o Menopause: At what age it is attained?

o Post Menopausal symptoms

After the full history, try to analyse the symptoms and think about the various diseases that
can occur in this particular patient. Try to write down the differential diagnosis at this stage
itself.

Step 1: What are the systems involved?

Step 2: Try to classify the diseases......Congenital, Traumatic, Infective(viral, bacterial, parasitic, fungal
etc) Inflammatory, Degenerative, malignant, others....and try to name the disease...

1.

2.

3.

EXAMINATION:

General Examination:

(Exam the patient from Head to Foot and look for abnormalities.)
The first point is whether the patient is comfortable at rest or not?

Then systematically examine......and look for signs.

Build/Nourishment/orientation/cooperation

Height/Weight/BMI

Facies

Scalp

Eyes....Conjunctiva, Cornea, pupils and others for pallor of Conjunctiva, Jaundice, Arcus Senilis, KF Ring,
and others.

Ear and Nose

Oral cavity (Mouth)...lips, inner side of cheeks, angle of the mouth, tongue, soft and hard palate, uvula
and others

Neck...Thyroid, lymph nodes and other swellings and sinuses

Upper and lower limbs and trunk

But mainly look for the following signs....

o Anemia, Jaundice, Clubbing, Pitting pedal oedema, rashes over the skin etc.

o Nervous system: look for neuro cutaneous markers

o Abdomen: Look for signs of liver cell dysfunction

o CVS: Markers of congenital heart disease

Vital Signs:

PULSE: Rate, Rhythm, Volume, Character, Condition of the vessel wall, all peripheral Pulses felt or not,
both radials equally felt or not, Radio Femoral Delay

BP: Lying and Standing; both upper limbs and at least in one of the lower limbs.

Respiratory Rate and Rhythm:

Temperature:
EXAMINTION OF CARDIOVASCULAR SYSTEM:

INSPECTION:

o Size and Shape of the chest: Look for Pectus Excavatum, Pectus Carinatum, kypho
scoliosis, pre cordial bulge.

o Pulsations:

 Over the precardium (Apical Impulse, Parasternal pulsations, Pulsations over the
Pulmonary and aortic areas)

 Pulsations over the Neck:

 Venous: JVP

 Arterial: Supra-sternal, Supra scapular, Carotid

 Abdominal Pulsations: Over the Epigastrium ( Aortic pulsations...Transmitted and

 Pulsations over the back of the chest: Intercostal vessels.

o Scar and swellings over the chest wall

PALPATION:

o Apical Impulse:

 Location

 Character ( Tapping, Normal, Hyperdynamic or Heaving)

 Palpable sounds and Thrill

o Left Parasternal Area:

 Palpable sounds and Thrill

o Pulmonary Area

 Palpable sounds and Thrill

o Aortic Area

 Palpable sounds and Thrill

 Palpable sounds and Thrill

PERCUSSION:

Delineate /Locate the following using appropriate clinical method

o Right cardiac border

o Left cardiac border

AUSCULTATION:

Method of auscultation (Inching Technique)

Steps:

Identify S1

Identify S2

Systole and Diastole

Look for systolic events: Murmurs and extra sounds

Look for diastolic events: Murmurs and extra sounds

IF MURMUR PRESENT,

Describe the murmur

o Timing: Systolic/Diastolic/Continuous

o Character: Rough and rumbling/musical/...

o Duration

o Intensity: Grading of murmurs.....1-6

o Variation of intensity with Respiration, Position of the patient other special

o Pitch: Low or High

o Conduction Vs Transmission of murmur

Mitral Area (Apical Area)

Identify S1 and S2
Characterize S1...Loud or soft,

Systolic events and Diastolic events

Parasternal Area

Identify S1 and S2

Systolic events and Diastolic events

Pulmonary Area

Identify S1 and S2

S2...Loudness of S2....Pulmonic component (P2) and Aortic component ( A2), describe P2...

Splitting of S2......Respiratory variation...fixed split.....reverse split etc.

Pulmonary ejection click

Systolic events and Diastolic events...mainly murmurs

Aortic Area

Identify S1 and S2

Characterize A2..Loud or soft

Aortic ejection click

Systolic events and Diastolic events

Tricuspid Area

Identify S1 and S2

Systolic events and Diastolic events

Other system Examination:

Respiratory system

Abdomen

CNS

Provisional Diagnosis

Differential Diagnosis
Investigations

Final Diagnosis

Etiology

Nature of cardiac disease

Complications if any

----------------------------------------------------------------------------------------------------