CARDIOVASCULAR ASSESSMENT FORMAT

Patient profile

Name: Occupation:
Age: Income:
Sex: Diagnosis:
Religion:
Education:
Ward: IP no: Bed no:
Address
DOA:
Chief complaints:

Date of starting care:

ASSESSMENT
A: HISTORY
PRESENT HISTORY
Presenting complaints
Dyspnoea
Onset
Duration
Progression
NYHA class
Aggravating or relieving factors
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
Chest pain
Site
Nature
Onset
Duration
Aggravating or relieving factors
No: of episodes
Syncope
Onset
Duration
Consciousness and memory before and after the episode
Differentiate from seizures
Fatigue
Daily activities affected
Palpitation
Exertional or paroxysmal
Regular or irregular
Duration
Severity
Cough
Hemoptysis: severity
Mild < 100 ml /d
Moderate: 100-150 ml/d
Severe: 150- 200 ml/d
Massive : >500 ml/d or 100 ml/d for more than 3 days
Congestive heart failure history
Edema of feet
Ascites
Pain in the right hypochondrium
Decreased urine output
Rheumatic heart disease history
Fever with sore throat
Fleeting joint pain and swelling- duration, which joints, treatment response, severity of pain
Involuntary movements
Nodules under the skin
Any injection given every one 3-4 weeks
Infective endocarditis history
High grade fever
Petechiae
Tender finger tips
Hemoptysis
Focal neurological deficits
Treatment
Pressure symptoms
Hoarseness of voice
Dysphagia
PAST MEDICAL/ SURGICAL HISTORY
Past history of hypertension, diabetes, CAD, dyslipidemia, cyanotic spells, TB, syphilis, childhood illnesses​ ​,
MI, angina., Rheumatic fever, HTN of pregnancy, Congenital heart problems, STDs, infections, Dental work
(S. viridans).
Treatment history
Any drugs taken:
▪ HRT.
▪ Thyroid drugs.
▪ Diabetic drugs.
▪ Prostate dz drugs.
▪ Steroids.
▪ Vasodilator (cause of ankle edema).
▪ Allergies.
▪ Allergies to drugs, dyes.
Previous hospitalization and reason for hospitalization
Investigations: angiogram.
Surgery: CABG, transplant, valve replacement, angioplasty.

FAMILY HISTORY
Hypertension
Diabetes
Coronary artery disease
Dyslipidemia
Congenital heart disease, history of consanguineous marriage
FAMILY STRUCTURE
 Name Age / Relationship Education Occupation Health Status
Sex

Family Tree
Personal History
Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew].pack years
Alcohol: amount taken per day, duration
Occupation: stress, work interruption.
Activity levels
High cholesterol diet
Sleep
Appetite
Socio Economic Status
B –PHYSICAL EXAMINATION

General appearance

Ht: Wt: BMI:

Vital Signs:
Temperature:
Pulse:
Respiratory Rate:
BP
Head & scalp
Shape , size, any abnormality
Lesions, scars
Infections and infestations
Skin
Warmth, tenderness, nodes, lesions, petechiae
Nails
Anemia
Clubbing, stage 1-5 (cyanotic heart disease, IE)
Cyanosis
Splinter hemorrhages (IE).
Capillary refill
Hands
Peripheral cyanosis
Arachnodactyly (Marfan's)
Pallor of palmar creases (anemia 2° to blood loss, malabsorption)
Osler nodes [0.5-1 cm red-brown painful subcutaneous papules on fingertips, palmar eminences] (IE)
Janeway lesions [rare, painless flat erythematous macules on thenar and hypothenar eminences] (IE)
Wrist: tendon xanthoma [yellow deposit over extensors] (type II hyperlipidemia).
Heat (thyrotoxicosis).
Tremor (thyrotoxicosis).
Pulse: rate, rhythm, character, radiofemoral delay, radioradial inequality
If suspect AR, assess 'water hammer pulse':
Arms
Take blood pressure.
IV drug injection scars (IE).
Optionally raise arm to see if less circulation
Face
Apprehension, pain (angina, MI, PE, etc)
Cushing's (HTN)
Acromegaly (CHF, HTN)
Paget's (high output failure)
Malar flush [thin face, purple cheeks] (mitral stenosis)
Earlobes (cyanosis).
Eyes
Xanthelasma [yellow plaque periobital deposits] (hypercholestolemia, DM).
Lid edema (myxedema, SVC syndrome, nephrotic syndrome, etc).
Exophthalmos, lid retraction (thyrotoxicosis).
Corneal arcus (severe hypercholesterolemia).
Blue sclera (Marfan's Ehlers-Danlos's [AR, ASD, MVP]).
Subluxated lenses (superior: Marfan's, inferior: homocystenuria).
Argyll-Robertson pupil (syphilis).
Ophthalmoscope fundi:
• Roth's spots [small red hemorrhage with pale center, due to vasculitis] (endocarditis).
• Hypertensive changes.
Ears
Cyanosis
Deformities
Low set ears
Nose
Deviated septum, nasal polyps
Mouth
Lips: central cyanosis.
Tongue underside: central cyanosis.
Tongue enlargement (amyloidosis).
High arched palate (Marfan's).
Breathing: dyspnea + wheezing (asthma, COPD, asthma, LV failure).
Breathing: Chyne-Stokes breathing (stroke, CHF, sedation, uremia
Neck
Use of accessory muscles of respiration (pulmonary edema, asthma, fulminant pneumonia, COPD)
Carotid: inspect for carotid pulsations.
Carotid: compress one carotid at a time [fingers behind neck, thumb at or below cricoid cartilage level.
Optionally use just L thumb to assess R carotid
Amplitude
Contour of pulse
Variations in amplitude
Carotid: auscultate bruit:
Use bell of stethoscope.
Tell pt. to hold their breath while you listen
JVP
JVP: inspect height, character.
JVP: Kussmaul's sign [change on inspiration].
Chest
Scars, including mitral valvotomy laterally on L breast.
Deformities, dressings, stitches, etc.
Visible pulsations.
Apex beat
Abdomen
Liver: find, examine edge.
Liver: pulsatile liver (tricuspid regurgitation).
Splenomegaly (endocarditis).
Abdominal Aortic Aneurysm
Back & Spine
Inspect for deformities (ankylosing spondylitis, with AR).
Percuss back (exclude an RVF pleural effusion).
Palpate sacral edema
Legs
Pedal edema.
Peripheral vascular disease.
Femoral pulse.
Varicose veins.
Ulcers.
Feet
Rest of peripheral pulses.
Achilles tendon xanthomata. Same signs as Hands and Fingernails.

Genitalia

SYSTEM WISE EXAMINATION

CARDIOVASCULAR SYSTEM
Appearance-dyspnoeic distress
Hyperpigmented (hemochromatosis cardiomyopathy, Addisonian hypotension).
Leg hanging over edge of bed: peripheral vascular
Dyspnoea
NYHA classification
● Class I: no symptoms with ordinary physical activity
● Class II: symptoms with ordinary activity, slight limitation of activity
● Class III: symptoms with less than ordinary physical activity, marked limitation of activity
● Class IV: symptoms at rest
Pallor, clubbing, cyanosis, edema
Pulse, BP, JVP, temperature
Skin-petechiae, osler’s nodes rheumatic nodules
Skeletal system –polydactyly, cubitus valgus
Dysmorphic features like Marfans syndrome
Peripheral signs of aortic regurgitation
Peripheral signs of infective endocarditis
Carotid thrill and bruit
INSPECTION:
Precordial bulge:
Precordial activities:
Apical impulse:
Pulsations:parasternal, epigastric, suprasternal, neck, left 2​nd​ ICS
Dilated veins:
Scars and sinuses:
PALPATION
Warmth&Tenderness:
Pacemaker boxes
Apexbeat:
Location:
Quality:
Left parasternal heave:
Grading
Grade I: visible but not palpable
Grade II: visible and palpable but obliterable
Grade III: visible and palpable but not obliterable
Palpable second heart sound:
Thrills:
Epigastric pulsations
AUSCULTATION
Heartsounds:
S1 &S2
loudness
split
Additional heart sounds:S3, S4
Other sounds:
Pericardial rub:
Opening snap
Click
Venous hum
Murmers:
Loudness
Quality
Location
Timing
Grading:
Grade I: very soft, heard under optimal conditions
Grade II: faint murmer but clearly audible
Grade III: moderately loud murmer but no thrill
Grade IV: loud murmer with thrill
Grade V: louder with thrill, can be heard away from the involved site (radiation)
Grade VI: murmer with thrill heard even if steth is lifted off from the chest wall
Best heard with
Radiation
Other relevant examination
Respiratory system
● Basal rales
● Pleural effusion
GIT
● Liver
● Spleen ascites
CNS
 ● Pupils
● Reflexes
● Focal neurological deficits
FINAL IMPRESSION