Cardiovascular System Examination (CVS) Proforma
General Physical Examination (GPE)Patient Position
• Examination performed in a well-lit room.
• Patient adequately exposed up to the waist.
• Patient lying comfortably in a supine position with the head end elevated to approximately 45°.
• Verbal consent obtained.
• Female attendant present (if examining a female patient).
General Appearance
• Comfortable at rest / Ill-looking / Dyspnoeic / Orthopnoeic / Cyanosed.
Vitals
• Pulse
Rate: __ beats/min
Rhythm: Regularly regular / Regularly irregular / Irregularly irregular
Volume: Normal / Low / High
Character: _______________
All peripheral pulses palpable: Yes / No
Radio-radial delay: Present / Absent
Radio-femoral delay: Present / Absent
Vessel wall thickening: Present / Absent
• Blood Pressure
__ /__mmHg
Arm: Right / Left
Position: Sitting / Supine
Method: Auscultatory
• Respiratory Rate
_____ breaths/min
Type: Thoraco-abdominal / Abdomino-thoracic
Use of accessory muscles: Present / Absent
• Temperature
Axillary temperature: ___ °F
General Physical Signs
• Pallor: Present / Absent
• Icterus: Present / Absent
• Cyanosis (Peripheral/Central): Present / Absent
• Clubbing: Present / Absent
• Pedal edema: Present / Absent
• Lymphadenopathy: Present / Absent
• Malar flush: Present / Absent
• Xanthelasma: Present / Absent
• Corneal arcus: Present / Absent
• Jugular Venous Pulse (JVP)
JVP: Elevated / Not elevated
Waveform: Normal / Abnormal
Hepatojugular reflux: Present / Absent
Examination of Hands and Peripheral Extremities
• Temperature of extremities: Warm / Cold
• Capillary refill time: Normal / Delayed
• Splinter haemorrhages: Present / Absent
• Osler nodes: Present / Absent
• Janeway lesions: Present / Absent
• Petechiae: Present / Absent
• Tendon xanthomas: Present / Absent
• Nicotine staining: Present / Absent
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Inspection
• Chest symmetry: Symmetrical / Asymmetrical
• Scars: Present / Absent
- Median sternotomy scar
- Left infraclavicular scar (Pacemaker)
• Sinuses: Present / Absent
• Dilated veins: Present / Absent
• Bony deformities: Pectus excavatum / Pectus carinatum / Others ______
• Precordial bulge: Present / Absent
• Apex beat visible: Yes / No (location?)
• Visible pulsations:
- Parasternal: Present / Absent
- Pulmonary area: Present / Absent
- Aortic area: Present / Absent
- Suprasternal area: Present / Absent
- Epigastric area: Present / Absent
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Palpation
Peripheral Examination
• Extremities warm: Yes / No
• Capillary refill time: Normal / Delayed
• Apex Beat
- Site:_______Intercostal space
- Position:_____ cm from midsternal line / Medial to mid-clavicular line
- Area occupied: _____intercostal space(s)
- Diameter:____cm / fingerbreadths
- Character: Normal / Hyperdynamic / Heaving / Tapping / Diffuse / Absent
• Parasternal Activity
- Parasternal heave: Present / Absent
• Thrills
- Aortic area: Present / Absent
- Pulmonary area: Present / Absent
- Tricuspid area: Present / Absent
- Mitral area: Present / Absent
- Other thrills: _______________
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Percussion
• Cardiac dullness: Within normal limits / Increased / Globular enlargement
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Auscultation
Areas Auscultated
• Aortic area
• Pulmonary area
• Tricuspid area
• Mitral area
* Examination performed using both diaphragm and bell.
Heart Sounds
• First Heart Sound (S1): Normal / Loud / Soft / Variable
• Second Heart Sound (S2)
Normal / Loud A2 / Soft A2 / Loud P2
Splitting: Normal / Wide / Fixed / Paradoxical
• Added Sounds
- S3: Present / Absent
- S4: Present / Absent
- Opening snap: Present / Absent
- Pericardial knock: Present / Absent
- Pericardial friction rub: Present / Absent
Other: _______________
• Murmurs
Murmur present: Yes / No
If present, document:
- Timing: Systolic / Diastolic / Continuous
- Site of maximal intensity: _______________
- Radiation: _______
- Pitch: Low / Medium / High
- Character:
- Effect of respiration and manoeuvres:_____
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How to Present Examination Findings
GPE
The patient is examined in a well-lit room, adequately exposed up to the waist, in a comfortable supine position with the head end elevated to approximately 45°, after taking verbal consent, in the presence of a female attendant (if female patient).
The patient appears comfortable at rest and is not in respiratory distress.
On General Physical Examination, his/her pulse rate is 68 beats/min, regularly regular, of normal volume and character. All peripheral pulses are palpable with no radio-radial or radio-femoral delay or vessel wall thickening. His/her blood pressure is 128/76 mmHg, measured from the right arm in sitting position by the auscultatory method. His/her respiratory rate is 18/min, thoraco-abdominal/abdomino-thoracic in type, without use of accessory muscles of respiration. His/her axillary temperature is 98.6°F. There is no pallor, icterus, cyanosis, clubbing, edema or lymphadenopathy.
Central cyanosis may be seen in cyanotic congenital heart disease, Malar flush may be present in mitral stenosis, Xanthelasma and corneal arcus may suggest hyperlipidemia, Clubbing may be seen in infective endocarditis and cyanotic congenital heart disease.
The jugular venous pulse is not elevated and demonstrates a normal waveform.
If elevated, the JVP may suggest right ventricular failure, constrictive pericarditis, tricuspid valve disease or cardiac tamponade.
The hands appear normal with no splinter haemorrhages, Osler nodes, Janeway lesions, tendon xanthomas or nicotine staining.
Splinter haemorrhages, Osler nodes, Janeway lesions and petechiae suggest infective endocarditis. Tendon xanthomas suggest hyperlipidemia.
Inspection
On inspection of the precordium, the chest appears bilaterally symmetrical with no scars, sinuses, dilated veins, bony deformities, precordial bulge or visible pulsations. The apex beat is not visibly displaced. There are no visible pulsations in the parasternal, pulmonary, aortic, suprasternal or epigastric regions.
A median sternotomy scar may indicate previous cardiac surgery, a left infraclavicular scar may indicate pacemaker implantation, a precordial bulge may suggest cardiomegaly or congenital heart disease, a visibly displaced apex beat may indicate cardiomegaly, visible parasternal pulsations may suggest right ventricular hypertrophy and visible epigastric pulsations may indicate right ventricular enlargement or an abdominal aortic aneurysm.
Palpation
The peripheral extremities are warm and capillary refill time is normal.
Cold extremities and delayed capillary refill may indicate low cardiac output states.
The apex beat is palpable in the left fifth intercostal space, just medial to the mid-clavicular line, occupying one intercostal space and approximately one fingerbreadth in diameter. It is normal in character.
The apex beat may be displaced inferolaterally due to left ventricular enlargement, hyperdynamic in mitral regurgitation and high-output states, heaving in hypertension and aortic stenosis, tapping in mitral stenosis, diffuse in dilated cardiomyopathy, or absent in obesity, emphysema and pericardial effusion.
No parasternal heave is palpable.
A parasternal heave suggests right ventricular hypertrophy.
No thrills are palpable over the aortic, pulmonary, tricuspid or mitral areas.
An apical diastolic thrill suggests severe mitral stenosis, a systolic thrill in the aortic area indicates severe aortic stenosis, a systolic thrill in the pulmonary area suggests pulmonary stenosis, a pansystolic thrill may occur in ventricular septal defect and a continuous thrill may occur in patent ductus arteriosus.
Percussion
Percussion of the precordium is generally of limited value. The area of cardiac dullness appears within normal limits.
Increased cardiac dullness may suggest cardiomegaly, while a globular increase in cardiac dullness may suggest pericardial effusion.
Auscultation
The heart is auscultated systematically over the aortic, pulmonary, tricuspid and mitral areas using both the diaphragm and bell of the stethoscope.
The first heart sound (S1) and second heart sound (S2) are normal in intensity and character. No abnormal splitting of S2 is appreciated. No added sounds or murmurs are heard.
S1 may be loud in mitral stenosis and soft in mitral regurgitation. A2 may be loud in systemic hypertension and soft in severe aortic stenosis. P2 may be loud in pulmonary hypertension. S2 may demonstrate wide splitting, fixed splitting or paradoxical splitting. Added sounds such as S3, S4, opening snap, pericardial knock and pericardial friction rub may be present.
No murmurs are heard.
A low-pitched mid-diastolic murmur at the apex suggests mitral stenosis. A pansystolic murmur radiating to the axilla suggests mitral regurgitation.
An ejection systolic murmur radiating to the carotids suggests aortic stenosis.
An early diastolic decrescendo murmur suggests aortic regurgitation.
A pansystolic murmur increasing with inspiration suggests tricuspid regurgitation.
A mid-diastolic murmur at the lower left sternal border suggests tricuspid stenosis.
An ejection systolic murmur at the pulmonary area suggests pulmonary stenosis.
A harsh pansystolic murmur suggests ventricular septal defect and a continuous machinery murmur in the left infraclavicular region suggests patent ductus arteriosus.
