Introduction

Right side of patient
Wash hands
‘May I now examine you? Are you in any pain?’

General Inspection

Look around bed for: medication, oxygen, insulin, chest leads, walking aids, medical-alert bracelet.
Does the patient look: well, breathless, well nourished. Any recognisable syndrome, how is the patient’s complexion?

Exposure
CVS: Strip to the waist; 45 sitting upright
‘Are you wearing anything beneath your own? Could you remove your top so that I can examine you please? We can use the sheet to cover you.’
Use bed sheet to maintain patient’s dignity while examining other systems.

Hands

‘May I have a look at your hands?’
Inspect dorsal and palmar aspects noting colour, skin texture, deformities and feel for temperature or sweating.

Look for tar-staining, finger clubbing, lipid deposits (xanthomata), palmar erythema, Dupryten’s, Osler’s nodes and Janeway lesions (Infective endocarditis).
Capillary refill – on chest

NAILS: koilonychias (spoon-shaped nail in iron deficiency), onycholysis (destruction), Beau’s lines (chronic disease), Mee’s lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), pitting (psoriasis/alopecia) and capillary nailbed pulsation (Quinke’s sign of aortic regurge).

WRISTS: for tenderness (hypertrophic pulmonary osteoarthropathy – lung ca), asterixis (CO2 retention flap, liver failure).
Test for CO2 retention flap. ‘Can you stretch out your arms and cock your wrists.’ While patient is doing this note the respiratory rate (count breaths for 15 seconds and x4)

Pulse
Palpate radial pulses
‘I’m now going to take your pulse.’
Rate: Count for 15 secs and x4 (60-100 is normal)
Rhythm: regular, irregular
Radial-radial delay
‘I’m going to raise your arm up.’
Raise arm for collapsing pulse while gripping wrist

Blood Pressure
‘I’m going to take your blood pressure’
Size cuff
Position relaxed arm at level of heart
Palpate brachial artery
Inflate cuff till brachial pulse occluded for maximum inflation pressure then deflate. Wait 15-20 seconds.
Listen with diaphragm and inflate cuff then gradually deflate at rate of 2mmHg/second
Note B.P. to 2mmHg

JVP
‘I’m going to have a look at a vein in your neck. Can you relax your head and turn your head slightly to the left.’
Pt slightly looking to the left
Shine light/torch
Note cm above angle of Louis (normal =3cm)

Face
‘I’m now going to look at your eyes. Could you look up to the ceiling for me.’
Eyes: Looking for anaemia, jaundice, corneal arcus, Kayser-Fleischer rings (Cu deposits, Wilson,s disease), xantholasma
Cheeks: Malar flush (mitral stenosis)
Mouth: Looking for central cyanosis, angular chelitis

Neck
‘I’m going to feel for the pulse in your neck and feel your windpipe. It may feel slightly uncomfortable’

Carotid pulse
Character & Volume: bounding pulses (CO2 retention, liver failure, sepsis), small volume (aortic stenosis, shock, pericardial effusions), collapsing (aortic incompetence, AV malformations, PDA), slow-rising (aortic stenosis), bisferiens (aortic stenosis+regurge), pulsus alternans ( strong then weak - LVF, AS, cardiomyopathy), pulsus paradoxus (systolic weakens with inspiration - severe asthma, pericardial constriction, tamponade).

Thorax
Inspect
Praecordium for scars (look in apex) and ask patient to identify, implantable devices, colour, surface vessels, muscular deformity, breathing.

CVS
Palpate
‘I’m going to examine your chest. I will feel for your heart and listen to your heart and lungs’
CVS feel for:
Apex Beat – Hand below nipple feeling for maximal impulse then pinpoint midclavicular line 5th intercostal space, note character.
Heave – palm on left sternal edge (thrusting pulsation indicating right ventricular enlargement)
Thrill – palm over aortic/pulmonary area (palpable murmur)

Auscultation
‘I’m going to keep my finger on your neck so I can compare your pulse with what I hear.’
Finger on carotid listen at mitral (apex) with diaphragm and bell.
‘Can you roll onto your left side.’ Listen over mitral area with bell in left lateral position. ‘Breathe in and out and hold’
Diaphragm over tricuspid (5th IC left sternal edge), pulmonary (2nd IC left manubrial edge) and aortic (2nd IC right manubrial edge) areas.
Listen with bell over carotids ‘Breathe in and out and hold.’

Identify 1st and 2nd heart sounds, listen for added sounds and murmurs.
Murmurs: Inspiration accentuates right sided murmurs, expiration accentuates left sided murmurs.
Character – ejection-systolic (AS), pansystolic (MR), early-diastolic (AR), mid-diastolic (MS).
Intensity – Graded systolic 1-6, diastolic 1-4.
1/6 Very soft
2/6 Soft but immediately detectable
3/6 Clearly audible, no thrill
4/6 Clearly audible, palpable thrill
5/6 Audible with stethoscope partially touching chest
6/6 Heard without stethoscope
Radiation – ESM of AS radiate to carotids, PSM of MR to axilla.

Peripheral Pulses
Palpate popliteal (behind knee), posterior tibial (behind medial malleolus) and dorsalis pedis (1st/2nd metatarsals on anterior ankle) pulses.
Check for pitting oedema at feet.