Case History Taking-Cardiovascular System

 Name:
 Age:
 Sex:
 Address:
 Occupation:

Chief Complaints:[ex:breathlessness,chest pain,palpitation]

History Of Presenting Illness:

Patient was apparently normal for …….days/months after that he/she developed …….

 Mode & cause of onset

 Duration
 Location
 Aggravating & relieving factors

Medical History: [ex:anemia,bleeding disorders,cardio respiratory disorders,allergies,GI

disorders,hypertension,diabetes,jaundice,kidney disease]

Family History:[ex:asthma,diabetes,cancer,heart disease]

Personal History:

Diet,oral habits,

General Examination:

 Conscious oriented
 No pallor/icterus/cyanosis/clubbing/pedal edema/lymphadenopathy
 Pulse rate:…../mt (regular/irregular) [Normal:
 BP:…../…… mmHg [Normal:120/80mmHg]
 Respiratory rate: …..mt [Normal:12-16/mt]

Systemic Examination:

 Inspection

Shape-normal? Symmetry/Asymmetry

Apical impulse………..ICS…………Mid Clavicular line

Scars

 Palpation

Apical impulse………..ICS…………Mid Clavicular line

Thrill (palpable murmur)

  Percussion –Skip
 Auscultation

NVBS heard

Mitral areas S1-S2 heard

Tricuspid areas S1-S2 heard

Aoric areas S1-S2 heard

Pulmonary areas S1-S2 heard

Other system : Normal

Diagnosis:

 Acquired valvular heart disease (mitral stenosis/mitral regurgitation/aortic stenosis/aortic

regurgitation)(with/without pulmonary hypertension,with/without CCF,with/without IE)

Investigation:

 Routine:CBC,Blood urea,Serum creatinine,Random Blood Sugar,u.routine, chest x-

ray,plasminogen activator,ECG
 Echocardiogram

Treatment:

 T.Lasix
 T.Enalapril
 T.Digoxin
 Symptomatic treatment

If tooth extraction planned IE prophylaxis

C.Amoxicillin 500 mg*4tab 1hr before procedure

If allergic T.Clindamycin 600 mg 1hr before procedure