Principles of physical
examination
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Steps for examination
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①•Permission , introduction & explanation
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② •General exam. -21/s
③ •Vital signs 89 20
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•Cardiovascular examination
•Completion : other area exam.,, bed side tests &
thanking the patient & help him
Preparation & i
• Wash your hands N
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• Introduce yourself to the patient if you have not already done so
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• check the identity of the patient
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• Ask the patients permission to carry out the examination
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• Give a brief explanation to the patient before you start. Further
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explanation/instructions can be given as you proceed.
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• 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. & 1 45: -
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General Observations
• Check visually from the end of the bed Note:
-• Obvious discomfort/pain n
-• ease of movement &(181 -1
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• whether breathless or not
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Colour - pallor, cyanosis in Fi
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Bluish discoluration
Items around the bed (e.g. Oxygen , ECG,
GTN spray, IV infusions) - 5 -
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Prosthetic valves may be audible
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Hands Examination
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• Inspect both hands; nails, back and palms.
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• You should be able to recognize, and know the significance of, the
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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
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• 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
Tular
venous
pressure :
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Body lying 450
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2 More Head to Left . (Apperance Right part of neck) .
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Jugaular rein
* in IF = JV appearence without More Head sides. S
Rig he Atrium .
Vital signs
•Pulses :rate , rhythm , volume , character , state of the arterial wall ,
radio-radial delay & radio-femoral delay
•BP : postural …. Lower limb ( radial ankle ratio )
•RR: high in pulmonary edema ….
•UOP : shock
•Temperature : fever in cardiology ( causes )
•Other : oximetry,, level of consciousness,,, peripheral temperature
• The local exam.
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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
Normally 5th intercostal space, left mid clavicular line. Will be
displaced in hypertrophy and dilatation
•Note the character of the apex beat. You should be able to
recognize and know the significance of common abnormalities
•If unable to feel the apex beat, roll the patient to the left
(however you cannot now comment on the location).
•If unable to feel palpate the Rt. Side
• 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
•Practical tips…. Criteria for each murmur
•Timing
•Site or max. intensity
•Radiation
•Character
•Relation to resp.
•Procedure
•Associated thrill
•Grade
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.
•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.
Practice Tip!
•Murmurs can sometimes radiate to areas where heart sounds cannot
normally be auscultated and may be exaggerated by certain
maneuvers.
•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).
Peripheral vascular examinatin
• All the peripheral pulses
• Color
• Hair loss
• Skin integrity
• Venous refilling
• Special test
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
