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Case Sheet Representation: Cardiovascular System

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1. Patient Identification

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2. Chief Complaints (with duration)

• Chest pain / discomfort — onset, duration, character, radiation, precipitating/relieving factors, associated symptoms
• Dyspnoea — at rest, on exertion, orthopnoea, paroxysmal nocturnal dyspnoea (PND)
• Palpitations — rate, rhythm, onset/offset (sudden vs. gradual)
• Syncope / pre-syncope — postural, exertional, or arrhythmic
• Oedema — location (dependent, presacral), pitting vs. non-pitting
• Fatigue / reduced exercise tolerance
• Cyanosis — central vs. peripheral
• Claudication — distance, rest pain

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3. History of Present Illness (HPI)

Chest Pain (Cardinal Cardiac Symptom)

• Site & radiation: precordial → neck, shoulder, or arms (ischaemic); back (aortic dissection); pleuritic (pericarditis, PE)
• Character: pressure, tightness, squeezing (ischaemia); tearing (dissection); sharp pleuritic (pericarditis/PE)
• Severity: 0–10 scale
• Duration: seconds/minutes/hours; continuous vs. episodic
• Precipitants: exertion, emotion, cold, rest
• Relieving factors: GTN, rest, position change (leaning forward — pericarditis)
• Associated features: sweating, nausea, vomiting, breathlessness

Women and elderly patients may present with atypical (non-classic) chest pain despite advanced coronary disease and require equal clinical suspicion. — Goldman-Cecil Medicine, p. 2503

Dyspnoea

• NYHA functional class (I–IV)
• Orthopnoea: number of pillows
• PND: frequency, duration
• Associated wheeze (cardiac asthma)

Palpitations

• Rate regularity; onset/termination (sudden = SVT/VT vs. gradual = sinus tachycardia)

Oedema

• Bilateral pitting oedema + elevated JVP → volume overload / heart failure / constrictive pericarditis
• Without JVP elevation → hypoalbuminaemia, venous insufficiency, CCB (dihydropyridine) use

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4. Past Medical History

• Previous cardiac events (MI, angina, rheumatic fever, cardiac surgery)
• Hypertension, diabetes, dyslipidaemia, obesity
• Chronic pulmonary disease (COPD — may mimic/complicate cardiac dyspnoea)
• Renal disease, thyroid disease, haematological disorders
• Haemochromatosis (restrictive cardiomyopathy), Marfan syndrome (aortic dilatation)
• Recent dental procedures or invasive procedures (if infective endocarditis is suspected)

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5. Drug History & Allergies

• Current medications (antihypertensives, anticoagulants, antiplatelets, diuretics, statins, antiarrhythmics)
• Dihydropyridine calcium channel blockers → ankle oedema
• Prior or current use of illicit drugs, steroids, NSAIDs
• Known drug allergies (specify reaction)

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6. Family History

• Premature atherosclerosis (1st-degree relatives <55 M / <65 F)
• Familial hypercholesterolaemia
• Inherited arrhythmia syndromes: Long QT syndrome, Brugada
• Hypertrophic cardiomyopathy
• Sudden cardiac death

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7. Personal & Social History

• Smoking: pack-years
• Alcohol: units/week
• Diet: salt, fat intake
• Exercise level
• Occupational exposures
• Travel history (Chagas disease endemic areas)

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8. Review of Systems (Relevant to CVS)

• Respiratory: cough, haemoptysis (mitral stenosis, LVF)
• Neurological: TIA/stroke (embolic source), syncope
• Renal: oliguria, nocturia (cardiac failure)
• Musculoskeletal: joint pains (rheumatic fever, SLE)

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9. General Physical Examination

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10. Systemic Examination

General (Head-to-Toe Inspection)

• Eyes: hypertensive/diabetic retinopathy, Roth spots (endocarditis), xanthelasma (hypercholesterolaemia), exophthalmos (thyrotoxicosis → arrhythmia)
• Mouth: central cyanosis, dental hygiene (endocarditis risk)
• Hands: clubbing (cyanotic CHD, endocarditis), splinter haemorrhages (endocarditis), peripheral cyanosis, koilonychia, Osler's nodes, Janeway lesions, capillary refill

Jugular Venous Pressure (JVP)

• Normal: ≤4.5 cm above sternal angle at 30°
• Raised JVP = right heart failure, tamponade, constrictive pericarditis, SVC obstruction
• Waveform interpretation:
  • a wave (presystolic): atrial contraction; prominent in RV non-compliance; cannon a wave = AV dissociation
  • c wave: tricuspid closure
  • x descent: atrial relaxation
  • v wave: venous filling; giant v wave = tricuspid regurgitation
  • y descent: tricuspid opening

The JVP is the single most important bedside measurement to estimate volume status. — Harrison's Principles of Internal Medicine 22E, p. 1904

Precordial Examination

• Chest deformity, visible pulsations (apex beat, parasternal heave, pulsatile neck vessels)
• Scars (sternotomy, lateral thoracotomy, pacemaker pocket, CABG vein harvest)

• Apex beat: location (normal: 5th ICS, MCL), character (heaving = LVH, thrusting = volume overload, tapping = MS)
• Parasternal heave (RV enlargement)
• Palpable thrills (systolic/diastolic); exact location

• Heart sounds S1 & S2: intensity, splitting (physiological vs. paradoxical vs. fixed)
• Added sounds: S3 (gallop — volume overload/HF), S4 (atrial gallop — stiff ventricle/HTN), opening snap (MS), ejection click, pericardial rub
• Murmurs: timing (systolic/diastolic/continuous), location, grade (Levine I–VI), radiation, character, effect of respiration/posture/Valsalva

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11. Vascular Examination

• Peripheral pulses: radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial — note: presence, symmetry, volume
• Carotid bruits (auscultation)
• Ankle-Brachial Index (ABI) if peripheral arterial disease suspected
• Varicosities, venous ulcers, signs of DVT
• Auscultation of abdomen: renal/aortic bruits
• Abdominal aorta: palpate for pulsatile expansile mass

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12. Respiratory Examination (Cardiac Correlation)

• Basal crepitations (pulmonary oedema)
• Pleural effusion (heart failure — right > left)
• Wheeze ("cardiac asthma")

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13. Abdomen

• Hepatomegaly (right heart failure — pulsatile if TR)
• Splenomegaly (infective endocarditis, portal hypertension)
• Ascites (chronic right HF)
• Dependent (presacral) oedema

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14. Investigations

Bedside / First-line

Laboratory

Imaging & Functional

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15. Summary & Problem List

• Age/sex + significant past history
• Presenting symptoms + duration
• Key examination findings
• Provisional diagnosis
• Differential diagnoses

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16. Management Plan

• Immediate: acute interventions (O₂, IV access, monitoring, medications)
• Investigations: pending
• Medical management: specific drug therapy
• Interventional/surgical: planned procedures
• Patient education & lifestyle: diet, activity, smoking cessation
• Follow-up: plan and timeline

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• Goldman-Cecil Medicine, International Edition — Chapter 39 (Approach to the Patient with Cardiac Disease), pp. 2491–2613
• Harrison's Principles of Internal Medicine, 22nd Edition (2025) — Chapter 246 (Cardiovascular Physical Examination), p. 1904