[cont. II] Day 5

CVS history taking report

Personal details

Chief complaint

History of presenting illness

Background /Past medical history/ Surgical history

Drug history: ALLERGIES, medications

Social history

Clinical examination

BP, HR

Systemic review (compulsory)

CVS, RS, GIT, CNS

Examination for the fingers: the splinter hemorrhages can be accentuated by shining a torch on the finger examined.

Auscultation:

1. Basic auscultaion: Mitral , Tricuspid, Aortic and Pulmonary

2. Accentuation of murmurs: Ask patient to breath IN to check for RIGHT side murmur and breath OUT for LEFT side murmur.

3. Ask patient to lean forward for aortic regurgitation murmur and lean to the left side for mitral stenosis murmur.

* cardiac risk factors are to be included in PMH:

- modifiable: dyslipidemia, diabetes mellitus, smoking, alcohol

- non-modifiable: 1st degree relative who have a history of heart disease