CVS Physical Examination

General Inspection

- Patient is alert, conscious, responsive, there is no sign of distress, no gross

deformities, no excessive sweating, doesn’t look pale and pallor, well built, well-
nourished and no medical gadget is attached.

Nails

- Pallor, cyanosis, finger clubbing, capillary refill, splinter hemorrhage

Palm of hands

- Muscle wasting (hypothenar & thenar), temperature (warm/ cold), nicotine stain,
callus, Osler node, Janeway lesion

Osler nodes are painful, on the finger tips. Janeway lesion is on the palm. They are
lesions of bacterial endocarditis

Radial pulse

- lateral to the tendon of flexor carpi radialis

- report pulse, rhythm, volume, compare the radial pulse on both hands and is there
any radio-radio delay

Brachial pulse

- Medial to the bicep tendon at ante-cubital crease

- If sphygmomanometer is provided, I will measure the BP. If not, the omit this part.

Face general inspection

- Symmetrical in size, no rash, no scar

Eye

- Sclera is whitish in colour, there is no jaundice

- Conjunctiva is pinkish in colour and there is no pallor  no anemia

- Xanthelesma, corneal arcus

Mouth

- Lips: colour, hydration level, angular stomatitis, central cyanosis

- Dental caries (infective endocarditis), tongue colour, ulcer, jaundice, central

cyanosis

Neck – Jugular Venous Pulse (JVP) and Carotid Pulse

Inspection of the neck for JVP and carotid pulse

Appreciate the JVP if cannot, do hepatojugular reflex. Measure the highest JVP wave
from sternal angle by using 2 rulers.

- The height of JVP is _cm above the water level when patient is lying 45° pop up.

Carotid pulse (ask patient to turn to left and right) and palpate the pulse

- Carotid pulse is felt anteriorly to sternocleidomastoid muscle

Anterior chest examination

1) Inspection of the chest (anterior and lateral)

- Size and shape (barrel chest, pigeon chest)

- Chest deformities (pectus excavatum, pectus carinatum)

- Surgical scar (midline sternal scar, lateral thoracotomy scar)

- Visible pulsation (tachycardia)

- Any pigmentation

2) Palpation

Apex beat  thrills- loud murmurs that can be felt by vibration (4 areas)  left
parasternal heave (must ask the patient to hold his breath and continue breathing
after you have done)  carotid pulse (ask patient to turn to the left and right- located
anteriorly and medially to the sternocleidomastoid muscle)

- Apex beat is felt at the 5th ICS left mid-clavicular line; there is no thrills, no
parasternal heave felt

3) Auscultation

Mitral  tricuspid  pulmonary  aortic (must palpate for carotid pulse)

- Upon auscultation, S1 is synchronized with carotid pulse followed by S2, there is no

murmurs and additional sound.

Mitral stenosis (ask patient to lean towards his left side, auscultate with bell)

- There is no mitral stenosis heard

Aortic murmurs “Right” (ask patient to sit up and lean forward, hold his breath when
auscultate)

- There are no aortic murmurs heard

Carotid bruits (use bell to auscultate – patient should hold his breath)

- There are no carotid bruits heard

Posterior chest examination

Auscultate lung bases for any fluid retention in Acute Heart Failure and pulmonary
oedema

- There are no crepitation / crackles heard

Sacral edema (Both sides)

- No sacral edema

Leg

Pitting edema

- There is no pitting edema at the medial malleolus

Peripheral Arterial Disease Physical examination

General Inspection

- Patient is alert, conscious, responsive, there is no sign of distress, no gross

deformities, no excessive sweating, doesn’t look pale and pallor, well built, well-
nourished and no medical gadget is attached

Inspection of Leg

Any thin and shiny skin, any hair loss, scars of previous healed ulcer, varicose veins,
foot ulcers (mainly on dorsum, but check between and under toes), color of the leg-
pale or dusky red, gangrene

Nails

- thickened and ridged?

Buerger’s Test

Ask patient to lie in supine position for 5 to 10 minutes and lift the leg vertically up to
450 for 1-2 mins and observe colour of the foot.

- No colour change is observed (if foot become pale and veins form “gutters” -PVD)

Gutters- empty vein with shallow grooves

Then, ask patient to sit up and hang the legs on the edge of the bed, observe for 2-3
mins. Color of the foot will become gradually red  reactive hyperemia (note the time
taken to change the colour from pale to red)

- There are no colour change seen

Palpation of the leg

Feel for temperature with the dorsum of your hand from foot up to leg and compare
with other side
- The temperature for both legs are warm and equal

Capillary refill (press for 5s)

- The capillary refill time is normal which is within 2s

Pulse

i) dorsalis pedis – on the dorsum of the foot, lateral to the extensor halluces longus
on the mid foot

ii) posterior tibial – posterior to the medial malleolus

iii) popliteal – midline of the popliteal fossa between head of gastrocnemius

iv) femoral – midpoint between the anterior superior iliac spine and pubic symphysis,
just below inguinal ligament

v) abdominal aorta – 2-3cm above the umbilicus, half way between umbilicus and
xiphisternum – use deep palpation technique to assess the width of vessel

If abdominal aorta pulsation is prominent  aneurysm (around 3cm in diameter)

Auscultation

Abdominal and femoral bruit

Peripheral Venous Disease Physical examination

General Inspection

- Patient is alert, conscious, responsive, there is no sign of distress, no gross

deformities, no excessive sweating, doesn’t look pale and pallor, well built, well-
nourished and no medical gadget is attached

Inspection of Leg

Any thin and shiny skin, any hair loss, scars of previous healed ulcer, varicose veins,
venous ulcer, swelling, foot ulcers (mainly on dorsum, but check between and under
toes), color of the leg- pale or dusky red, gangrene

Look for enlarged torturous veins along the course of superficial veins and at the
groin & knee

Ankle Brachial Pressure Index (ABP)

Normally BP in the arms and legs should be the same. If obstruction  systolic
pressure in the limb reduced  hard to listen by stethoscope  use doppler
ultrasound to listen blood flow

ABP: to diagnose peripheral arterial disease to assess degree of obstruction and

progression of disease
Technique of measuring ABP Index

i. Patient lying supine for 10-15mins for BP to stabilize

ii. Palpate for brachial pulse
iii. Place the cuff in normal position on upper arm
iv. Put ultrasound gel over brachial artery. Lightly place the probe of the hand-
held Doppler machine at the angle of 45-600 to the artery
v. Inflate the cuff to 20mmHg above the last audible pulse
vi. Deflate the cuff slowly and record the pressure at which doppler signal is first
heard
vii. Place the cuff over lower calf above malleoli
viii. Locate the dorsalis pedis artery, measure the systolic pressure
ix. Locate the posterior tibial artery and measure systolic pressure
Highest ankle systolic BP
x. Calculate the brachial index, 𝑥 = Highest brachial systolic BP

Interpretation:

Normal > 0.9 ; Arterial disease 0.8-0.9 ; Severe arterial disease <0.5

Respiratory Physical examination

General Inspection

- Patient is alert, conscious, responsive, there is no sign of distress, no gross

deformities, no excessive sweating, doesn’t look pale and pallor, well built, well-
nourished, no medical gadget is attached, no sputum bowl or oxygen mask

Nails

- Pallor, cyanosis, finger clubbing, capillary refill

Palm of hands

- Muscle wasting (hypothenar & thenar), temperature (warm/ cold), nicotine stain,
callus

- Fine tremor and flapping tremor

Radial pulse

- lateral to the flexor carpi radialis

- report pulse, rhythm, volume, compare the radial pulse on both hands and is there
any radio-radio delay

Brachial pulse

- Medial to the bicep tendon

- If sphygmomanometer is provided, I will measure the BP. If not, the omit this part.

Face general inspection

- Symmetrical in size, no rash, no scar

Eye

- Sclera is whitish in colour, there is no jaundice

- Conjunctiva is pinkish in colour and there is no pallor

- Horner syndrome: ptosis, anhydrosis, enophthalmus, miosis

Nose

- Symmetrical, nasal defect, discharge, foreign bodies, flaring of alae nasi

Mouth

- Lips: colour, hydration level, angular stomatitis, central cyanosis

- Dental caries, tongue colour, ulcer, jaundice, central cyanosis

Neck

Trachea alignment

- There is no trachea deviation since the paratracheal space for both sides are equal.

Anterior chest examination

1) Inspection of the chest (anterior and lateral)

- Size and shape (barrel chest, pigeon chest)

- Chest deformities (pectus excavatum, pectus carinatum)

- Surgical scar (bypass surgery)

- Visible pulsation (tachycardia)

- Any pigmentation

* Chest movement (at the end of the bed) – The chest rises up when patient is
breathing in and move down when breathing out. The chest movement for both sides
are equal and symmnetrical

2) Palpation

- Apex beat is best felt at 5th ICS left mid-clavicular line

- Chest expansion – ask patient to breath in and out; clavicle, above and below
nipple

(Good chest expansion and the movement is equal on both sides)

- Tactile fremitus – ask patient to say 99; apex of the lung, 2 areas above nipple, 1
below, and 2 on lateral sides
(The resonance is felt and equal on both sides)

3) Percussion

- apex of the lung  clavicle  2 areas above nipple  area below nipple  2 on
lateral sides

(The percussion note is in good resonance, and equal on both side)

4) Auscultate

(use mouth to breath in and out)

- apex of the lung  clavicle  2 areas above nipple  area below nipple  2 on
lateral sides

(Good air entry, vesicular breath sounds are heard, there is no additional sound)

-Vocal resonance – ask patient to say 99

(Resonance is heard and it is equal on both sides)

Skin Lesion Physical Examination *describe skin lesion* OSCE

General Inspection

-Patient appearance whether is comfortable, conscious, alert and etc

Vital signs
∞ Type
-Pulse, respiratory rate and temperature ∞ Shape and margin
∞ Arrangement
Skin
∞ Distribution
i) Types

- Basic lesion: macules, papule, nodule, pustule, purpura, plaque, vesicle

- Sequential lesions: scale, hyperkeratosis, exudation, ulcer, lichenification

- Colour of the lesion: white (leukoderma, hypomelanosis); black (blue, gray);

Red (erythema, ciolaceous)

- Palpation: consistency (soft, hard, firm, fluctuant); mobility; presence of

tenderness; estimate of depth (dermal or subcutaneous);
fixation (whether is attach to skin or not)

ii) Shape and margin

- Shape: Round, umbilicated, polygonal, annular, serpiginous

- Margin: well defined, ill defined

iii) Arrangement
 - Group: annular, linear, herpetiform, zosteriform

- Disseminated: scattered discrete, confluent (involve whole area)

iv) Distribution

- Extend: localized, generalized, isolated single

- Pattern: symmetrical, intertriginous area (between folds), site of pressure,

exposed area

Hair and nails

-scaly, white patches, dystrophic nails, onycholysis and pitting

Mucous membranes

-White striation (Lichen planus), hairy leukopenia (HIV), Koplik’s spot (measles)

General medical examination

Terminology of primary skin lesion

Macule : flat area of discolouration, <0.5cm

Patches : flat area of discolouration, >0.5cm

Nodule : elevated, hard, and solid lesion

Papule : elevated solid area, <0.5cm

Plaque : elevated solid area, >0.5cm

Vesicle : elevated fluid-filled lesion, <0.5cm

Bullae : elevated fluid-filled lesion, >0..5cm

Pustule : elevated pus-filled lesion

Wheal : elevated, rounded or flat-topped area, > 2cm

Cervical lymph node physical examination

General inspection (front, sides and behind)

- visible bulky node, overlying skin, dilated vein, visible pulsation,

Palpation (using the pulps of the fingers to palpate one side at each time)

Start under the chin and moving posteriorly towards occiput

Submental  submandibular  tonsillar  preauricular  postauricular  occipital

 superficial cervical  deep cervical  posterior cervical  supraclavicular

Report: any tenderness felt, pain at which site and cervical lymph node

Axillary lymph node physical examination

General inspection (front, sides and behind)

- visible bulky node, overlying skin, dilated vein, visible pulsation,

Palpation (using the pulps of the fingers to palpate one side at each time)

Central nodes  anterior (pectoral) nodes  posterior (subscapular) nodes  lateral

nodes (head of humerus)  apical nodes

Report:

i) Site (generalized or localized)

ii) size: circular shape

iii) consistency: rubbery, hard, matted

iv) fixation/ attachment: to skin or deep structure

v) tenderness

vi) overlying skin: any inflammation