CVS Case Sheet PDF

**[CVS PROFOMA ]** **NAME** **AGE** **SEX** **OCCUPATION** **ADDRESS** **SOCIOECONOMIC STATUS** **[PRESENTING COMPLIANTS]** Chest Pain / Shortness Of Breath / Palpitations Hemoptysis / Syncope / Sweeling Of Feet **[H/O PRESENTING ILLNESS]** **[CHEST PAIN]** Duration / Onset / Site / Type...

**[CVS PROFOMA ]** **NAME** **AGE** **SEX** **OCCUPATION** **ADDRESS** **SOCIOECONOMIC STATUS** **[PRESENTING COMPLIANTS]** Chest Pain / Shortness Of Breath / Palpitations Hemoptysis / Syncope / Sweeling Of Feet **[H/O PRESENTING ILLNESS]** **[CHEST PAIN]** Duration / Onset / Site / Type / Nature Of Pain Aggrevating / Relieving Factors / Associated With Sweating / Nausea / Vomitings / SOB Progression Episodes - Episodic/ Continous Lasting / Radiation **[BREATHLESSNESS]** Duration / Onset / Progression / Grading NYHA Orthopnea / Platypnea / Trepepnea / PND Aggrevating / Relieving Factors **[PALPITATIONS]** Duration / Onset / Progression / Grading NYHA Regular / Irregular At Rest / Exertion Associated With SOB Aggrevating / Relieving Factors **[HEMOPTYSIS]** Duration / Onset / Progression / Episodes Amount / Fresh Blood / Altered [**SYNCOPE** ] Duration / Onset / Progression / Episodes Lasting / Aggrevating / Relieving Factors Relation With Exertion **[SWELLING OF FEET]** \[**DEPENDENT OEDEMA---SACRAL**\] Duration / Onset / Site Aggrevating/Relieving Factors Time Of Day Variation **GENERAL HISTORY** Appetite **** Loss Of Weight Fatigue / Sleep / Bowel Bladder Habits / Fever Cyanotic Spells / Oliguria **[PAST HISTORY]** **CCF** H/O Anorexia / Right Hypochondrium Pain / Pedal Edema Orthopnea / PND **RHD** Fever With Sore Throat / Fleeting Joint Pain H/O Taking Penicillins **INFECTIVE ENDOCARDITIS** H/O Fever / Dental Procedures / Git Genitourinary Procedures **CHD** Failure Of Cry After Birth / Failure To Thrive Recurrent Rti / Squatting / Episodes Cyanotic Spells / Consangunity H/O Diabetes / HTN / Asthma / PTB / Unprotected Sex CAD / COPD / CVA / Malgnancy **[PERSONAL HISTORY]** Smoking / Alochol Bowel And Bladder Habits Diet - Veg / Mixed Sleep Habits Loss Of Weight / Appetite **[FAMILY HISTORY]** H/O CHD / IHD / HTN / DM / SCD **[TREATMENT HISTORY]** Any Rx Received So Far H/O Drug Allergy / Reactions Any Surgical Intervention / Chemotherapy **[MENSTRUAL / OBSTERITIC HISTORY]** Menarche / Duration / Quantity Any Dysmenorrhoea / Amenorrhoea No Of Pregnancies / Complications / Mode Of Delivery H/O Recent Delivery **[GENERAL EXAMINATION]** **BUILT / NOURISHMENT** **PALOR / ICTERUS** **CYANOSIS** -- Central / Peripheral **CLUBBING** -- Bilateral / Unilateral / Pandigital / Limited **PEDAL EDEMA** -- Bilateral / Unilateral / Painless / Painful / Pitting(Soft/Hard) / Nonpittig / Extension/ Regional Lymphadeopathy / Siginificant Lymphadenopathy **[MARKERS OF CONGENITAL HEART DISEASE]** **DWARFISM / GIGANTISM** **HEAD / NECK** - Low Set Ears / Hyperteleroism / Mongoloid Facies / High Arched Palate / Webbed Neck **TRUNK -** Kyphoscoliosis / Chest Wall Deformities **UPPER LIMBS -** Absent Radius / Syndactyly / Polydactyly Arachnodactyly Simian Crease **LOWER LIMBS -** Rocker Bottom Feet / Sandla Gap **RHEUMATIC FEVER** - Arthritis / Erythema Marginatum Subcutaneous Nodules / Sydenhams Chorea **INFECTIVE ENDOCARDITIS --** Anemia / Fever / Jaundice Splinter Hemorrhages / Clubbing / Splenomegaly Arthritis / Oslers Nodes / Roth Spots / Janeway Lesions **ATHEROSCLEROSIS -** Arcus Senilis / Xanthelasma / Nicotine Staining / Xanthomas **MARFANOID HABITUS** - Arm Span / Height Ratio / Upper Segment And Lower Segment Ratio / Wrist Sign / Thumb Sign **[VITAL SIGNS]** **PULSE -** Rate / Rhythm / Volume / Character / Felt In All Peripheral Pulses / No Radioradial Delay / Radiofemoral Delay / Apex Pulse Deficit / Condition Of Vessel Wall **BLOOD PRESSURE -** **HILLS SIGN** **RESPIRATORY RATE --** Rate / Regular Or Not / Type - Abdominothoracic Or Thoracoabdominal **TEMPERATURE** - **[CVS EXAMINATION]** **[INSPECTION OF NECK]** **JVP** - Pressure/ Waveforms **CAROTIDS** **TRACHEA** - Midline/ Shifted **THYRIOD** **[INSPECTION OF CHEST]** **CHEST WALL SHAPE & SYMMETRY** **PRECORDIAL BULGE** **CHEST WALL DEFORMITIES** **DILATED VEINS / SCARS / SINUSES** **APICAL IMPULSE** - Site / Diffuse/ Localized **PULSATIONS** - Parasternal / Pulmonary / Aortic / Suprasternal / Epigastric / Supraclavicuar / Interscapular **[PALPATION]** **APICAL IMPULSE** -- Site / Normal /Tapping / Heaving / HyperDynamic / Other Specific Characters **PALPABLE SOUNDS& MURMURS** **PULSASTION** - Parasternal Heave Grading Palpable P 2, Pulmonary Arterial Pulsations / Valve P2 Palpable Aortic / Suprasternal **THRILL -** Precordial / Carotid Thrill **DILATED VEINS** - Direction Of Flow **[PERCUSSION]** **UPPER BORDER OF LIVER DULLNESS** **RIGHT BORDER** - Coresponds To Rt Sternal Border **LEFT BORDER** - Coresponds To Apex Beat **NO DULLNESS BEYOND APEX BEAT** **IIND ICLS LT SPACE DULLNESS** - Normal **[AUSCULTATION]** **[MITRAL AREA]** **S1** - NORMAL/ LOW / **LOUD** **S2** -- **HEARD / S3 / S4** **OPENING SNAP / MITRAL CLICKS** **MDM - A LOW PITCHED, ROUGH RUMBLING MID DIASTOLIC MURMUR OF GRADE\-\--IS HEARD WITH THE BELL OF STETHOSCOPE AND PRESYSTOLIC ACCENTUATION WITH THE PATIENT IN THE LEFT LATERAL POSITION WITH EXPIRATION.NON RADIATING** **PSM OR HSM - A HIGH PITCHED, SOFT BLOWING SYSTOLIC MURMUR OF GRADE \-\-\-- IS HEARD WITH THE DIAPHRAGM OF STETHOSCOPE CONDUCTED TO THE AXILLA AND THE BACK OR BASE WITH THE PATIENT IN THE LEFT LATERAL POSITION WITH EXPIRATION** **[TRICUSPID AREA]** **S1 / S2 / S3 / S4** **MDM : A LOW PITCHED, ROUGH RUMBLING MID DIASTOLIC MURMUR IS HEARD WITH THE BELL OF STETHOSCOPE AND PRESYSTOLIC ACCENTUATION WITH THE PATIENT IN THE SUPINE POSITION WITH INSPIRATION** **PSM OR HSM : A HIGH PITCHED,SOFT BLOWING HOLO SYSTOLIC MURMUR OF GRADE\-\-\-- IS HEARD WITH THE DIAPHRAGM OF STETHOSCOPE WITH THE PATIENT IN THE SUPINE POSITION WITH INSPIRATION.** **[PULMONARY AREA]** **S1 / S2** **S2 SPLIT** **P2 LOUD / SINGLE 2^ND^ HEART SOUND** **PULMONARY EJECTION CLICK** **ESM : A HIGH PITCHED, CRESCENDO DECRESCENDO EJECTION SYSTOLIC MURMUR OF GRADE\-\-\-- IS HEARD WITH THE DIAPHRAGM OF STETHOSCOPE WITH THE PATIENT IN THE SUPINE POSITION WITH THE BREATH HELD IN INSPIRATION.** **EDM : A HIGH PITCHED, SOFT BLOWING EARLY DIASTOLIC MURMUR IS HEARD WITH THE DIAPHRAGM OF THE STETHSCOPE WITH THE PATIET IN THE SITTING POSITION LEANING FORWARD WITH INSPIRATION** **[AORTIC AREA]** **S1 / S2** **EJECTION CLICK** **ESM : A HIGH PITCHED,ROUGH CRESCENDO DECRESCENDO EJECTION SYSTOLIC MURMUR OF GRADE\-\-\-- IS HEARD WITH THE DIAPHRAGM OF STETHOSCOPE CONDUCTED TO THE CAROTIDS WITH THE PATIENT IN THE SITTING POSITION WITH EXPIRATION.** **EDM : A HIGH PITCHED, SOFT BLOWING EARLY DIASTOLIC MURMUR IS HEARD WITH THE DIAPHRAGM OF THE STETHSCOPE WITH THE PATIET IN THE SITTING POSITION LEANING FORWARD WITH EXPIRATION** **[SECOND AORTIC AREA(ERBS AREA)]** **S1 / S2** **EDM : A HIGH PITCHED, SOFT BLOWING EARLY DIASTOLIC MURMUR IS HEARD WITH THE DIAPHRAGM OF THE STETHSCOPE WITH THE PATIET IN THE SITTING POSITION LEANING FORWARD WITH EXPIRATION** **[INFRACLAVICULAR AREA(GIBSONS AREA])** **CONTINUOUS MURMUR , A HIGH PITCHED, CONTINOUS MACHINERY MURMUR WITH A CRESCENDO DECRESCENDO QUALITY THAT BEGINS IN SYSTOLE, PEAKS AROUND S2 AND CONTINUES IN TO ALL OR PART OF DIASTOLE CONDUCTED TO THE BACK IS HEARD WITH THE DIAPHRAGM OF THE STETHOSCOPE IN THE LEFT 1^ST^ ICS IN SUPINE POSITION** **[OTHER SYSTEMS]** - **RS -** Tracheal Position / Movement Of Chest Wall / Breath Sounds / Added Sounds **ABDOMEN -** Soft Liver / Hepatojugular Reflex / Ascites / Spleen **CNS -** NFD **[DIAGNOSIS]** **ACQUIRED VALVULAR HEART DISEASE / RHEUMATIC ETIOLOGY / WITH PULMONARY HYPERTENSION / AF / EVIDENCE OF CONGESTIVE HEART FAILURE / WITH OR WITHOUT SIGNS OF ACTIVE RHEUMATIC FEVER / INFECTIVE ENDOCARDITIS** **CONGEITAL CYANOTIC OR ACYNATOIC HEART DISEASE / WITH LEFT TO RIGHT SHUNT OR RIGHT TO LEFT SHUNT / WITH PULMONARY HYPERTENSION / WITH EVIDENCE OF CONGESTIVE HEART FAILURE / WITH OR WITHOUT SIGNS OF INFECTIVE ENDOCARDITIS / AF**