Principles of physical examination

PHYSICAL EXAMINATION Overview

• The cardiovascular examination should include the following:

General examination including inspection from the end of the bed, general examination of :

• Hands / pulse

• Arms (pulses, BP)

• Face & Neck

Examination of the chest including : Inspection ,Palpation , percussion & Auscultation

Completing the exam.: Auscultation of the lung bases ,examination for sacral oedema, examination of the feet/legs , abdominal exam. & fundoscopy

peripheral vascular examination

Preparation• Wash your hands

• Introduce yourself to the patient if you have not already done so

• check the identity of the patient

• Ask the patients permission to carry out the examination

• Give a brief explanation to the patient before you start. Further explanation/instructions can be given as you proceed.

• Equipment: Stethoscope +/- fundoscopy

• Patient position Ideally the patient should be reclined at 45 degrees, hands by the side and chest exposed (In female patients the bra ( take her agreement ) will need to be removed but Do not expose the patient's chest until you are ready to examine the precordium.

General Observations

• Check visually from the end of the bed Note:

• Obvious discomfort/pain

• ease of movement

• whether breathless or not

Colour - pallor, cyanosis

Items around the bed (e.g. Oxygen , ECG, GTN spray, IV infusions)

Prosthetic valves may be audible

Hands• Inspect both hands; nails, back and palms.

• You should be able to recognize, and know the significance of, the following: clubbing, splinter hemorrhages, anemia, peripheral cyanosis, Osler nodes, janeway lesions & tar staining.

• Feel the radial pulse

Arms• feel for both brachial pulses

• o Located medial to the biceps tendon at the cubital fossa:Note the character and volume

• Blood pressure

May need to be measured in both the right and left arm (certainly on the first occasion); standing (if the patient is at risk of postural hypertension) and supine.

• May choose to leave this until the end of examination.

Face

Gently pull down lower eyelids and ask the patient to look up. Inspect for:

- Pale conjunctiva of anaemia and congestion of conjunctiva of polycythemia

Corneal arcus and xanthalasma of hypercholesterolaemia

- Look for mitral facies - distinctive flush (malar flush) associated with mitral stenosis

• Ask patient to open mouth and then stick out their tongue

• Look for central cyanosis

• Note dental hygiene

• Look for the lips

Neck • Check Jugular Venous Pressure (JVP)

• With the head resting back on the pillow ask the patient to turn the head to the left Look for pulsation along the right internal jugular vein.

• The height of the pulsation is measured vertically in cm from the sternal angle Add 5cm to get the JVP.

• You should know how the JVP can be differentiated from carotid pulsation

• Not change with respiration , position and abdominal jugular reflex

• JVP :The center of the right atrium is 5cm vertically below the sternal angle when the patient is at 45 degrees. A normal JVP is therefore 8 cm of H2o

• The Chest

INSPECTION• With the chest exposed look carefully for

• Scars, visible pulsation, pacemaker, abnormal chest shape ,hair distribution , gynecomastia and dilated veins

PALPATION Apex Beat

• Using the palmar surface of the fingers locate the lowermost lateral point that pulsation of the heart can be felt. This is the apex beat

• o Normally 5th intercostal space, left mid clavicular line. o Will be displaced in hypertrophy and dilatation

• Note the character of the apex beat. You should be able to recogniseand know the significance of common abnormalities

• If unable to feel the apex beat, roll the patient to the left bringing the heart into closer proximity to the chest wall and try again (however you cannot now comment on the location).

• Palpation for palpable 2nd heart sound

• in ( pulmonary and systemic hypertension )

• General Palpation

• Place the hand flat onto the chest to the left and then to the right of the sternum. You should

• recognise and know the significance of:

• Heave‟ - A sustained forceful pulsation

• „Thrill‟ - A palpable murmur felt as a shudder or vibration beneath the finger.

AUSCULTATION

•

• On auscultation you need to be able to identify the first (S1) and second (S2) heart sounds, any additional sounds, such as an S3 or S4 and any valvular murmurs.

• There is no standard order for auscultation, but it is common practice to start at the apex and proceed towards the base. The order suggested below is a logical one and results in minimal movement for the patient.

• Listen with the diaphragm of the stethoscope over the 4 main areas.

• These areas do not relate exactly to the anatomical position of the valves. It is the area at which the sound of each valve is best heard.

• 5th intercostal space, left midclavicular line

• o Apex, mitral valve

• o S1 heard best here

• 4th intercostal space, left sternal edge

• o Tricuspid valve

• 2nd intercostal space, left sternal edge

• o Pulmonary valve

• o S2

• 2nd intercostal space, right sternal edge

• o Aortic valve

• o S2

Practice Tip!

• If you are unsure which is the first and second heart sound or where a murmur is occurring, palpate the carotid pulse while listening to the heart. The carotid pulse occurs with S1 or systole.

• Loudest area, whether it occurs in systole or diastole and whether it radiates to any other area.

Practice Tip! • Murmurs can sometimes radiate to areas where heart sounds cannot

normally be auscultated and may be exaggerated by certain maneuvers.

• Left-sided heart murmurs are accentuated by holding the breath in expiration and right-sided heart murmurs are accentuated by holding the breath in inspiration.

• Listen over left axilla : Mitral regurgitation

• Roll the patient to the left, listen will the bell over the mitral area:Enhances auscultation of murmur of mitral stenosis

• Listen over carotid arteries : Aortic stenosis

• Sit the patient forward, ask them to breathe out and hold it while you listen over the 5th intercostal space at the left sternal edge:Aortic regurgitation

Completing the Examination • While the patient is still sitting forward:

• Auscultate the lung bases for any evidence of pulmonary oedema.

• Inspect the sacrum for signs of peripheral edema (in a bed bound patient this is the lowest point of gravity causing fluid to collect here) & legs edema ( for mobile patients).

Completing the Examination

• Abdominal exam for ascites, hepatosplenomegaly.

• Signs of right heart failure

• Fundoscopy

• In cases of diabetes, hypertension, endocarditis.

• Bedside investigations

• Such as temperature and urine dipstick

• Cover patient /assist to redress if necessary

• Thank the patient

Peripheral vascular examinatin

• All the peripheral pulses

• Color

• Hair loss

• Skin integrity

• Venous refilling

• Special test

Ankle:Brachial Pressure Index (ABPI) • ABPI is measured using a hand-held Doppler and a sphygmomanometer. The patient must

be rested in the supine position or ankles raised to the same height as the heart.

• The systolic pressure is measured in the dorsalis pedis and posterior tibial arteries of the same leg by holding the Doppler probe over the pedal artery while a blood pressure cuff wrapped around the ankle is inflated.

• The pressure at which the Doppler signal disappears is the systolic pressure in that artery.

• The blood pressure (BP) should be taken in both arms and the ABPI is calculated as follows:

• ABPI = Highest ankle systolic pressure/ Highest brachial systolic pressure

• A value for ABPI should be obtained for each leg

• Normally the systolic BP in legs > arms so normal ABPI should be >1 in the supine position.

• ABPI is a sensitive marker of arterial insufficiency. Typical values of ABPI are:

>1 = Normal

<0.9 = Abnormal

0.5 - 0.9 = Claudication

<0.5 = Critical Ischaemia

Buergers Test • With the patient lying supine, stand at the foot of the bed. Raise the

feet and support the legs at 45˚ to the horizontal.

• When the legs are elevated look for pallor of the sole of the foot along with emptying of the dorsal foot veins

• Ask the patient to sit up and swing the legs over the edge of the bed. In the presence of critical limb ischaemia the foot will turn a deep red („sunset foot‟) due to reactive hyperaemia

Allen's Test • This tests the collateral blood flow to the hand

• Identify both radial and ulnar pulses and apply pressure simultaneously in order to occlude the arteries.

• The patient should clench and unclench the hand until the palm goes pale.

• Release pressure from the ulnar artery and observe for the distinct pink colouration (reactive hyperaemia) of the palm.

• If the re-colouration of the palm is < 5 seconds, then the circulation to the hand via the ulnar artery is adequate

• The procedure can then be repeated to check the patency of the radial artery by releasing the radial artery first

Trendelenbergs Test • Used to test for saphenofemoral junction incompetence - only in the

presence of varicose veins

• Ask the patient to sit on the edge of the examination couch elevate the limb as far as is comfortable for the patient and empty the superficial veins by „milking‟ the leg with the leg still elevated, exert digital pressure (or apply a tourniquet) over the saphenofemoraljunction locate the femoral artery by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction is about 2 fingers breadth below the inguinal ligament ask the patient to stand

• In the presence of saphenofemoral junction incompetence the varicose veins will not refill until the digital pressure (or tourniquet) is removed

Check points

• Referred back to pulse exam in S2

• Seminar for

peripheral pulse ex.

JVP exam.

Apex exam