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CVS Examination Proforma

This document contains an examination proforma for cardiovascular system examination. It outlines the steps to examine general appearance, vital signs, jugular venous pressure, peripheral signs, lymph nodes, oral cavity, and peripheral edema. It then details examination of the precordium, apex beat, pulsations, percussion findings, auscultation areas including heart sounds and murmurs. The diagnosis would identify the predominant and other involved valves or any congenital heart disease. It also specifies etiology, arrhythmias, heart failure, and infective endocarditis.

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Anantha Krishnan
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190 views4 pages

CVS Examination Proforma

This document contains an examination proforma for cardiovascular system examination. It outlines the steps to examine general appearance, vital signs, jugular venous pressure, peripheral signs, lymph nodes, oral cavity, and peripheral edema. It then details examination of the precordium, apex beat, pulsations, percussion findings, auscultation areas including heart sounds and murmurs. The diagnosis would identify the predominant and other involved valves or any congenital heart disease. It also specifies etiology, arrhythmias, heart failure, and infective endocarditis.

Uploaded by

Anantha Krishnan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CVS Examination Proforma

General examination
• Elderly Gentleman /lady
• Build,
conscious, oriented to time place and person
• Is he in respiratory distress- usage of accessory muscles of respiration –
please name them
• Lying comfortably in a propped up position
• Make a note of IV line, NG, CBD or any other drains/ Mobility Aids
(Elderly)

• Pulse - ##/min regular in rhythm, normal volume, character, Normal


arterial wall, all peripheral pulse equally felt, no radio-radio or radio-
femoral delay – Or you can say all peripheral pulses equal and bilaterally
synchronous.
• Pulse Deficit – In case of AF or Ectopics

• BP - ##/##mm Hg right arm in supine position


- ##/##mm Hg left arm in supine position
- ##/##mm Hg Right Leg
- ##/##mm Hg Left Leg

• JVP – Raised Y/N, if Y **cm, which wave - a, c v or x, y descend


• Hepatojugular reflex +/-

• Clubbing Y/N. if Y grading


• Peripheral cyanosis +/-
• Central cyanosis +/-
• Pallor +/-
• Icterus +/-
• Immature or mature cataract +/- or Pseudophakia (Elderly)
• Arcus senilis +/-. Pupil size
• Fundus – Roths Spot+/-, HTN/DM Retinopathy changes with grading
• Tongue appearance – Macro/micorglossia, Geographic, Fissured, Black
hairy tongue, Bald tongue, ulcers etc…

• Axillary, cervical lymph nodes, Supraclavicular, Epitrochlear & Inguinal


+/- →Size, Shape, Consistency, Matting+/-, Fixed+/-
(Mention about nodes when u Suspect TB/Sarcoidosis only – features of
constrictive pericarditis or restrictive cardiomyopathy)

• Oral Cavity – Hygiene +/-, Caries +/-, No of missing tooth (Elderly)


• Sacral Edema +/-
• Pedal edema +/-, If Y Pitting/Non Pitting, extend

• Periperal Signs of Aortic Regurgitation such as ….

• Periperal Signs of Marfans (Young)

• Periperal Signs Infective endocarditis/Rheumatic fever(Youngs)

• Peripheral signs of insulin resistance such as xanthelesma, xanthoma ,


acanthus nigericans or skin tags

• Periperal Signs of Genetic Disorder/Syndromes/Dysmorphic feature


(Young)

CVS system Examination


Inspection
• Precordium – Normal/bulge
• Apex Beat – Visible or not/Double or Single/Space
• Other Visible Pulsation - Aortic A2/Pulmonary
P2/carotid/Suprsternal/suprclavicular/epigastric/Suzmans sign/Hepatic

• Shape of chest wall – Elliptical/pectus excavatum/carnatum/barrel


shaped
• Kyphosis +/-
• Scoliosis +/-
• Skin overlying the chest wall
o Dilated Veins chest wall or flanks +/-
o Scars – Mid or Lat thoracotomy scars +/-
Infraclavicular Scar +/-
o Sinuses +/-

Palpation
• Apex beat - LV/RV Apex
o Space - left 5th/6th ICS ## cm lateral or medial to Mid clavicular
line/ ##cm anterior to anterior axillary line
o Single or Double Apex
o Type of Apex – Normal/Hyperdynamic/Irregular/tapping or
Heaving
(Always look for scoliosis before commenting on Apex beat)
• Parasternal Heave +/-, if +e grading
• Palpable (Shocks) P2 or A2/Click/Opening snap/thrills

Percussion
▪ Right Border corresponds sternum
▪ Left Border correspond with apex beat
▪ No Evidence Pericardial effusion/Dextrocardia/DCMY
▪ Dullness in Aortic space +/-
▪ Dullness in Pulmonary Space +/-
Auscultation

• S1 - Mitral or Tricuspid
Loud/Soft/Variable/Splitting/Reverse Splitting

• S2 – Absent/Soft/Loud A2 or P2/Single S2/Splitting/Wide fixed


Split/Reverse split

• S3 – LVS3 or RVS3

• S4 – Present/Absent
• Gallops +/-
• Opening Snap +/-
• Clicks +/-
• Pericardial Rub +/-, Pericardial Knock +/-, Prosthetic sound +/-

• Murmors

• Mitral – MDM/PDM/Austin Flint /Functional PSM


(To describe the character of murmur, Grading, Radiation, intensity
with respiration, Dynamic auscultation findings)

• Tricuspid – MDM/PSM/Function MDM or PSM


(To describe the character of murmur, Grading, Radiation, intensity
with respiration, Dynamic auscultation findings)

• Aortic – ESM (Gallavardin Phenomena)/EDM/Function Murmor


(Elderly)
(To describe the character of murmur, Grading, Radiation, intensity
with respiration, Dynamic auscultation findings)

• Erbs Area or 2nd Aortic – EDM with description of murmur


(To describe the character of murmur, Grading, Radiation, intensity
with respiration, Dynamic auscultation findings)

• Pulmonary – ESM/Graham Steel Murmor/ Functional Murmor


(To describe the character of murmur, Grading, Radiation, intensity
with respiration, Dynamic auscultation findings)

• Gibsons Area – Continous Murmor

• Early Systolic murmur/ Late systolic murmur/ late Diastolic Murmor


to be mentioned only if it is very evident

• Carotid bruie +/- , Subclavian Bruie +/-


DIAGNOSIS – congenital or acquired or degenerative valvular heart disease
mention predominant valve disorder, followed by other
valves in the order of severity

or

congenital heart disease cyanotic or acyanotic

ETIOLOGY – RHEUMATIC/I.E/INFLAMMAORY/CONGENITAL
PAH – Y/N
SINUS RHYTHM OR AF OR ECTOPICS
IN CARDIAC FAILURE OR NOT
NO EVIDENCE OF I.E

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