M.D.

GENERAL MEDICINE
CASE PROFORMA – CARDIOVASCULAR SYSTEM

Examination of young/middle aged/ elderly Female/Male patient

GENERAL EXAMINATION

Patient is conscious/not
Oriented/not
Comfortable/not
Co-operative/not
Built
Nourishment
Febrile/afebrile
Palor
Icterus
Cyanosis-central/peripheral
Clubbing – bilateral/unilateral, pandigital/limited
Pedal edema – bilateral/unilateral, painless/painful, pitting(soft/hard)/non-pitting, extension,
regional lymphadenopathy
Significant lymphadenopathy

MARKERS OF CONGENITAL HEART DISEASE-

DWARFISM/GIGANTISM
HEAD AND NECK – low set ears, hyperteleorism, mongoloid facies, high arched palate,
webbed neck
TRUNK – kyphoscoliosis, shield chest, widely placed nipples, pectus carinatum, pectus
excavatum, cryptorchidism, umbilical hernias
UPPER LIMBS – absent radius, cubitus valgus, syndactyly, polydactyly, arachnodactyly,
simian crease
LOWER LIMBS – rocker bottom feet, sandle gap

MARKERS OF RHEUMATIC FEVER - arthritis, erythema marginatum, subcutaneous

nodules, sydenham’s chorea

MARKERS OF INFECTIVE ENDOCARDITIS - anemia, fever, jaundice, splinter

haemorrhages, clubbing, splenomegaly, arthritis, osler’s nodes, roth spots, janeway lesions

MARKERS OF ATHEROCLEROSIS - arcus senilis, xanthelasma, ear lobe creases,

obesity, nicotine staining, xanthomas

MARFANOID HABITUS
high arched palate, dislocation of lens, thumb sign, wrist sign, arm span/height ratio, upper
segment/lower segment ratio

FUNDUS
 VITAL SIGNS

PULSE: rate, rhythm, volume, character, felt in all peripheral pulses/not,

radioradial/radiofemoral delay, apex pulse deficit, condition of vessel wall.
Measure three pulse rates in Atrial Fibrillation.

BLOOD PRESSURE: _____mm of Hg measured in the Left Upper limb in the sitting
position and ______mm of Hg measured in the Left Lower limb with the patient in the prone
position.
Look for Hills sign.
Measure Blood Pressure thrice in Atrial Fibrillation.

PERIPHERAL SIGNS OF AORTIC REGURGITATION -

HEAD AND NECK: lighthouse sign, landholfi’s sign, becker’s sign, muller’s sign, de
musset’s sign, corrigan’s sign
TRUNK: gerhardt’s sign, rosenbach’s sign
UPPER LIMBS: locomotor brachii, pulses bisferiens, water hammer pulse, quinke’ sign
LOWER LIMBS: traube’s sign, pistol shot femorals, duroziez murmur, hills sign

RESPIRATORY RATE: _____/min, regular/not, type-thoracoabdominal/abdominothoraxic

TEMPERATURE: _______F measured in the axilla

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:
JUGULAR VENOUS PULSE:
1. Pressure
2. Waveforms
INSPECTION:
Chest wall shape and symmetry,
Precordial bulge, Pectus carinatum/excavatum
Kyphoscoliosis
Dilated veins, scars, sinuses
Apical impulse
Pulsations – epigastric, parasternal, pulmonary, aortic, suprasternal, supraclavicular,
infraclavicular, suprascapular, interscapular, hypochondrial

PALPATION:
Kyphoscoliosis
Apical impulse – normal/absent/tapping/heaving/hyperdynamic/other specific characters
Pulsations – Epigastric pulsations,
Parasternal Heave – Grading,
Palpable Pulmonary valve closure,
Palpable aortic, suprasternal, supraclavicular, infraclavicular, suprascapular,
interscapular, right hypochondrial pulsations
Thrills – Precordial/Carotid thrill
Dilated veins – direction of flow
PERCUSSION:
Right Heart Border
Left Heart Border
Gerhardt’s sign

AUSCULTATION:
MITRAL AREA:
S1, S2, S3, S4,
MITRAL CLICKS
MDM: A low pitched, rough rumbling mid diastolic murmur of Grade ___ is heard with the
bell of the stethoscope with opening snap and presystolic accentuation with the patient lying
down in the left lateral position with the breath held in expiration
PSM or HSM: A high pitched, soft blowing holo systolic murmur of grade___ is heard with
the diaphragm of the stethoscope conducted to the axilla and the back or base with the patient
lying down in the left lateral position with the breath held in expiration

TRICUSPID AREA:
S1, S2, S3, S4
MDM: A low pitched, rough rumbling mid diastolic murmur of Grade ___ is heard with the
bell of the stethoscope with opening snap and presystolic accentuation with the patient in the
supine position with the breath held in inspiration.
PSM or HSM: A high pitched, soft blowing holo systolic murmur of grade___ is heard with
the diaphragm of the stethoscope with the patient in the supine position with the breath held
in inspiration. The intensity of the murmur increases with inspiration indicating a positive
Carvallo’s sign

PULMONARY AREA:
S1, S2, S2 SPLIT, P2 LOUD,
PULMONARY EJECTION CLICK
ESM: A high pitched, crescendo decrescendo ejection systolic murmur of grade ___is heard
with the diaphragm of the stethoscope with the patient in the supine position with the breath
held in inspiration
EDM: A high pitched, soft blowing Early Diastolic Murmur of grade___ is heard with the
diaphragm of the stethoscope with the patient in the supine position with the breath held in
inspiration

AORTIC AREA:
S1, S2
EJECTION CLICK
ESM: A high pitched, crescendo decrescendo ejection systolic murmur of Grade ___is heard
with the diaphragm of the stethoscope conducted to the carotids with the patient in the sitting
position with the breath held in expiration
EDM: A high pitched, soft blowing Early Diastolic Murmur of Grade___ is heard with the
diaphragm of the stethoscope better heard in the Second Aortic Area with the patient in sitting
position leaning forward with the breath held in expiration

SECOND AORTIC AREA(ERB’S AREA)

S1, S2
EDM: A high pitched, soft blowing Early Diastolic Murmur of grade___ is heard with the
diaphragm of the stethoscope with the patient in sitting position leaning forward with the
breath held in expiration

INFRACLAVICULAR AREA (GIBSON’S AREA)

CONTINUOUS MURMUR: A high pitched, continuous machinery murmur of Grade ___
with a crescendo decrescendo quality that begins in systole, peaks around S2, and continues
into all or part of diastole conducted to the back is heard with the diaphragm of the
stethoscope in the left first intercostals space with the patient in supine position.

DYNAMIC AUSCULTATION:
Hand grip

EXAMINATION OF OTHER SYSTEMS

RESPIRATORY SYSTEM:
Added sounds

ABDOMEN:
Ascites, hepatosplenomegaly

NERVOUS SYSTEM:
FND

DIAGNOSIS

ACQUIRED VALVULAR HEART DISEASE OF PROBABLE RHEUMATIC

ETIOLOGY ________WITH PULMONARY HYPERTENSION AND ATRIAL
FIBRILLATION WITH EVIDENCE OF CONGESTIVE HEART FAILURE
WITH/WITHOUT SIGNS OF ACTIVE RHEUMATIC FEVER AND INFECTIVE
ENDOCARDITIS.
or

CONGENITAL CYANOTIC/ACYANOTIC HEART DISEASE, ________________,

WITH LEFT TO RIGHT/RIGHT TO LEFT SHUNT WITH PULMONARY
HYPERTENSION WITH EVIDENCE OF CONGESTIVE HEART FAILURE,
WITH/WITHOUT SIGNS OF INFECTIVE ENDOCARDITIS OR ATRIAL
FIBRILLATION