Cardiovascular exam
examining the heart and circulatory system
Examination of any system should start with inspection. The patient should be sitting comfortably at 45° with adequate exposure of the praecordium. The room should be quiet and warm. Stand on the patient’s right hand side and, when palpating, use your right hand.
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1. INTRODUCTION
A. Wash hands with water or alcohol gel.
B. Introduce self and seek permission to examine the cardiovascular system.
C. Confirm patient’s name and date of birth.
D. Ask if patient is currently in any pain.
E. Position patient at 45 degrees with chest adequately exposed.
2. GENERAL INSPECTION
A. Look for signs of breathlessness, discomfort or pain.
B. Examine face, eyes and mouth for signs of clinical anaemia, cyanosis, xanthelasmata, corneal arcus and malar flush.
C. Examine hands to assess circulation for warmth and capillary refill. Look for evidence of peripheral cyanosis, nicotine staining, clubbing, splinter haemorrhages, koilonychia (nail spooning.)
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INSPECTION:
Observe patient generally for breathlessness (tachypnoea suggests heart failure), peripheral cyanosis and evidence of pain or discomfort.Observe face for colour. Is he unduly pale or highly coloured? Consider if he could be anaemic or polycythaemic. Is there a malar flush (indicative of mitrial stenosis)?
Observe eyes. Look for corneal arcus and xanthelasmata (sign of hyperlipidaemia). Is he anaemic? Turn down lower eyelid and look at colour. It should be pink.
Observe mouth. Look at colour of lips. Look under tongue for central cyanosis.
ASSESSMENT OF HANDS
Feel hands to assess circulation, warmth, filling of veins. Check capillary refill time. Is there any peripheral cyanosis?Look for evidence of anaemia - pallor of palmar creases, pallor under lower eyelids, koilonychia (nail spooning). Palpate the nail bed and assess for finger clubbing by opposing the dorsal surfaces of two nails. The diamond shaped window is absent if the nails are clubbed (a sign of anaemia).
Look for evidence of infective endocarditis – splinter haemorrhages.
Look at hands for evidence of long term smoking -nicotine staining.
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3. PULSES
A. Palpate both radial pulses and assess rate and rhythm. Assess for collapsing pulse.
B. Palpate right carotid pulse and assess volume and character.
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ASSESSMENT OF RADIAL PULSE
- Rate (normal is 60-100 bpm)
- Rhythm
- Collapsing pulse
Count the rate per minute. (Count for 15 seconds and multiply by four. You will require a second hand on your watch)
Assess the rhythm: Is it regular? If it is not, is it occasionally irregular, as when an ectopic heart beat occurs, or is it totally irregular as in atrial fibrillation?
ASSESSMENT OF CAROTID PULSE
- Volume
- Character
Check the volume. A large volume suggests a hyperdynamic circulation; small volume suggests a low cardiac output.
Assess the character or shape of the pulse. Does it rise slowly as in aortic stenosis when it is called an anacrotic pulse? Or does it fall away quickly, as does the collapsing pulse of aortic regurgitation? Slow rising pulses are less obvious in the peripheral pulses, hence the need to assess character at the carotid. A double-impulse pulse is indicative of mixed aortic valve disease.
Collapsing pulse. Another way to check for a collapsing pulse is to hold up the patient’s right arm and let his radial pulse beat against the flat of your hand. If present, a slapping sensation caused by a collapsing pulse can be noted.
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4. JUGULAR VENOUS PULSE ASSESSMENT
A. Assess right internal jugular vein with patient at 450. Check for hepatojugular reflux.
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Jugular Venous Pulse - JVP
The JVP correlates with the right atrial pressure and hence an elevated JVP may indicate right heart failure. It may also give valuable clues in the assessment of valvular lesions. Thus assessment of the JVP is part of the evaluation of the right side of the heart.Visual assessment of the pressure within the right internal jugular vein gives an indication of right atrial pressure (RAP). This in turn reflects right atrial filling and emptying, and gives a useful indicator of cardiac disease.
JVP assessment is an important but difficult skill to master. We need to be able to imagine or “visualise” the internal jugular vein.
Although the external jugular veins are fairly readily seen, they do not give reliable information. One problem is that we cannot actually see the internal jugular vein itself and we therefore require to visualise the vein. However, although the lower part of the internal jugular vein itself lies deep between the clavicular and sternal heads of sternocleidomastoid muscle, its pulsations can be seen in a normal person lying at 450 (degrees). The pulsation does not arise from the vein but reflects changes in pressure within the right atrium.
One essential element is to make sure that the neck is relaxed. Position the patient at 450. Ask the patient to turn his head slightly to the left and let his neck “sink” into the pillow. Look between the heads of sternocleidomastoid just above the clavicle for the pulsations of the right internal jugular vein.
It is worth looking at both sides of the neck for the clearest pulsation, and “sky-lining” the neck sometimes helps. (Stand slightly back from the patient and look across the neck.) Often in young fit subjects, the pressure is low and the vein tends to be empty at 45 degrees. Gentle pressure, just above the clavicle, will fill the vein and it will tend to bulge anterior to sternocleidomastoid and empty on release. Performing the Valsalva manoeuvre (forceful expiration against a closed glottis) may also help to fill the vein.
The double waveform (a and v) of venous pulsation (compared with an arterial pulse) is impalpable and can be stopped by gentle compression. This helps to distinguish it from arterial pulsation which cannot easily be obliterated. Gentle pressure below the right costal margin will elevate the JVP briefly, however it has no effect on arterial pulsations. (Hepatojugular reflux) If this effect lasts longer than 5 seconds, it could be an indicator of right heart failure.
Assess the height of the JVP. It is measured as the vertical height of the highest point of pulsation above the sternal angle, by imagining a horizontal line drawn from the upper level of pulsation to a point vertically above the sternal angle. (Note that this is not the same as the sternal notch. The sternal angle or Angle of Louis is continuous with the second costal cartilage.)
The height of JVP should be less than 4cm vertically above the sternal angle.
To recap, the normal upper limit of height of the JVP is 3cm vertically above the sternal angle. The right atrium lies approximately 5cm below the sternum. So this figure of a maximum height of 3cm corresponds to a right atrial pressure (RAP) of 8cm water. Textbooks may give right atrial pressure in mmHg and cause you some confusion. In order to convert cm of water to mmHg multiply by 0.75.
8cm water x 0.75 = 6mmHg
A
RAP greater than 8cm water or 6mmHg may indicate a problem of right
heart function, usually right heart failure secondary to left heart
failure or pulmonary disease. Other important causes include fluid
overload, superior vena caval obstruction, tricuspid regurgitation and
conduction blocks and arrhythmias. A low pressure may indicate that the heart is under filled due to hypovolaemia e.g. dehydration, blood loss.
The waveform of the JVP should also be noted. It has 2 visible peaks, the a and the v wave but don’t worry overly at this stage about visualising them - focus on the height. Click here for more detail.
In practice the JVP takes very little time to assess. However you will require to practise!
It is an important, but difficult skill to master.
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5. INSPECTION AND PALPATION OF PRAECORDIUM
A. Inspect praecordium (chest) for shape, respiratory rate, scars and visible apex beat.
B. Palpate praecordium for heaves and thrills. Locate the apex beat and assess character.
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ASSESSMENT OF PRAECORDIUM
INSPECTION
The praecordium is the front of the chest overlying the heart.Look for abnormal chest shape, respiratory rate, operation scars, pacemaker and visible pulsations. In thin people the apex beat may be seen to pulsate. Look for abnormal cardiac pulsations e.g. left ventricular aneurysm.
Brief guide to common scars:
- Midline – sternotomy scar – CABG/valve replacement.
- Left – thoracotomy scar (diagonal from under left breast to left axilla) – mitrial valvectomy for mitrial stenosis.
- Pacemaker – under skin inferior to left clavicle.
PALPATION
Feel for- the apex beat
- left parasternal impulse or “heave” and
- aortic and pulmonary “thrills”
Locate the apex beat accurately with the flat of and fingers of your right hand. Count down the ribs from the sternal angle. The normal apex beat should be in the 5th intercostal space in the mid clavicular line. Decide if the apex beat is normal or displaced. Lateral displacement suggests an enlarged heart. Asking the patient to lean forward may help locate the apex beat if it is hard to palpate.
Character of apex beat. Normal or abnormal? If abnormal, is it tapping (as in mitral stenosis), heaving (aortic regurgitation) or thrusting (left ventricular hypertrophy)?
Left parasternal palpation
Place your outstretched right hand just to the left of the sternum, with your fingers pointing towards the neck. You will feel normal respiration. A left parasternal heave (an abnormal finding) will lift the heel of your hand with each heart beat. This would suggest right ventricular hypertrophy.
Thrills
A thrill is a palpable vibration caused by turbulent blood flow and is always pathological. Feel for a thrill (rather like a cat purring) at the apex, the upper part of the praecordium and in the sternal notch. The commonest cause of a thrill is aortic stenosis.
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6. AUSCULTATION OF PRAECORDIUM
A. (Initially whilst palpating the carotid pulse) auscultate the praecordium, for heart sounds and murmurs in all of the 4 key areas. Use both bell and diaphragm. Position patient on left side and auscultate with bell in expiration.
B. Auscultate in left axilla for radiation of a murmur, and auscultate carotids for radiation and bruits.
C. Sit patient forwards. Auscultate in expiration with diaphragm at lower left sternal edge.
D. Auscultate the lung bases with diaphragm. Feel for sacral oedema.
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AUSCULTATION FOR HEART SOUNDS AND MURMURS
There is no “correct” or “incorrect” auscultation routine. Find a routine that suits you.(As a guide for you, auscultation in a routine examination should take approximately 2 minutes. A third of this time should be concentrated on the mitral area. Of course any abnormal findings will increase the time spent on auscultation.)
Initially auscultate whilst palpating the carotid pulse with your left fingers (2nd 3rd and 4th fingers) to distinguish S1 from S2 and therefore assist in identification of systole and diastole.
Listen to each auscultatory component in at least the four classical auscultation areas: -
apex, lower left, upper left and right sternal edges. Known as the:-
apex, lower left, upper left and right sternal edges. Known as the:-
- mitral/apex area, (5th intercostal space, ICS, mid clavicular line)
- tricuspid area, (around the 3rd, 4th and 5th left ICSs, at the left sternal edge, LSE)
- pulmonary area (2nd left ICS lateral to sternum, LSE) and
- aortic area (2nd right ICS lateral to sternum).
Listen systematically to the auscultatory events in the cardiac cycle i.e. 1st and 2nd heart sounds (S1 and 2) and listen in the systolic and diastolic intervals for added sounds and murmurs. Time events with simultaneous palpation of the carotid.
Use both the bell and diaphragm appropriately in the 4 areas – remember that the bell should only be placed lightly on the skin. In particular use the bell at the apex for low frequency sounds (i.e. murmurs) and the diaphragm at the base for high frequency sounds.
Roll your patient slightly onto his left side and listen in the 5th ICS with the bell for the low frequency mid diastolic murmur of mitral stenosis. (Listen in full expiration. This may enhance a murmur.)
Auscultate in the axilla with the diaphragm for radiation and comparative loudness of a systolic murmur. (e.g. the pan systolic murmur of mitral regurgitation radiates to the axilla.)
In addition auscultate with the diaphragm over both carotids for bruits and radiation of murmurs, (the ejection systolic murmur of aortic stenosis radiates to the neck.)
Next sit your patient forwards and listen with the diaphragm at the lower left sternal edge, in expiration, for the high frequency diastolic murmur of aortic regurgitation.
Finally, with the diaphragm, auscultate at the lung bases for the crackles of left ventricular failure.
While your patient is sitting forwards feel for sacral oedema. Press over the sacrum for 10 seconds. Lift thumb and look for indentation.
A summary of the clinical findings of the 4 main valve problems (aortic regurgitation, aortic stenosis, mitral regurgitation, mitral stenosis) may be found at:-
http://www.aic.cuhk.edu.hk/web8/valvular_heart_disease.htm
There are several sites on the internet where you can listen to heart sounds and murmurs e.g.
http://home.cwru.edu/~dck3/heart/listen.html
Grading of murmurs
| Grade | Thrill | Murmur |
| 1/6 | Absent | Very quiet |
| 2/6 | Absent | Quiet |
| 3/6 | Absent | Easily audible |
| 4/6 | Present | Loud |
| 5/6 | Present | Very loud |
| 6/6 | Present | Audible without stethoscope |
7. OTHER AREAS
A. Lay patient flat and palpate abdomen for hepato/splenomegaly and aortic pulsation/dilatation. Auscultate for renal and femoral bruits.
B. Assess for radiofemoral delay. Palpate the femoral, popliteal and foot pulses. Feel for ankle oedema.
C. Measure and record BP.
D. Ophthalmoscopic examination. Look for evidence of hypertensive retinopathy.
E. Test urine with dipstix.
F. Examine any observation charts available. Pulse, BP, Temperature, Urine Output.
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OTHER AREAS
Assessment of abdomen
Palpate superficially over the nine regions.Perform deep palpation to assess for an enlarged liver. Start in the right iliac fossa and progress to the right upper quadrant.
Perform deep palpation to assess for an enlarged spleen, again starting in right iliac fossa and then progressing towards the left upper quadrant.
Assess for ascites.
Auscultate for renal and femoral bruits.
Assessment of other pulses and peripheral oedema
- Assess for radiofemoral delay (indicates coarctation of aorta).
- Palpate and compare the femoral (at the midpoint of the inguinal ligament), popliteal (located at the back of the knee with a flexed knee – use both hands pressing towards the lateral aspect) and ankle/foot pulses (posterior tibial (located below the medial malleolus, lateral to the extensor hallucis longus tendon) and dorsalis pedis.)
- Feel for ankle oedema. Press on medial aspect of lower shin – if it is present, find the level at which it stops. Sacral odema may also be present.
Measure and record blood pressure
Measure and record B.P.
Ophthalmoscopic examination
Look for evidence of hypertensive retinopathy.
Test urine with dipstix
Examine any observation charts available
- Pulse
- BP
- Temperature
- Urine Output
8. CONCLUSION
A. Thank patient and wash hands with alcohol gel or water.
B. Summarise and present findings in patient’s notes and orally.
Summarise and present your findings in patient’s notes and orally.
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Respiratory exam
Examination of any system should start with inspection. The patient should be sitting comfortably at 45° with adequate exposure of the praecordium. The room should be quiet and warm. Stand on the patient’s right hand side and, when palpating, use your right hand.
1. INTRODUCTION
2. INSPECTION
A. Look for signs of breathlessness, discomfort or pain. Use of accessory muscles.
B. Examine face, eyes and mouth for colour and central cyanosis.
C. Look at chest shape, movement, scars and deformities.
D. Examine hands to assess circulation for warmth and venodilation. Look for evidence of tar staining and finger clubbing. Look for flapping tremor.
3. PALPATION
A. Palpate radial pulse and assess rate and rhythm.
B. Count respiratory rate.
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INSPECTION
It is best to have the patient sitting on the bed at 45° or upright. Observe patient generally for evidence of pain or discomfort or breathlessness.Listen for audible inspiratory stridor (upper airway obstruction) and expiratory wheeze (asthma). As patient talks, listen for hoarseness (laryngitis, lung cancer ® laryngeal nerve palsy or laryngeal cancer) and pattern of speech e.g. interrupts speech flow to take a breath.
Observe the chest for scars, (e.g. thoracotomy scar or chest drain scars in second intercostal space mid-clavicular line or in 4th, 5th or 6th intercostal spaces axilla (possibly indicate pneumothorax, pleural effusion).
Observe chest for shape, including asymmetry, any deformity, (e.g. kyphoscoliosis) and also if increased anterior-posterior (AP) diameter (barrel shaped) as evidence of hyperinflated chest and air trapping. In air flow obstruction (e.g. COPD) there may be a large AP diameter with little lateral expansion. Prominent chest wall veins would suggest SVC obstruction.
Observe pattern of breathing, nasal flaring, use of accessory muscles of respiration, intercostal recession or indrawing (also watch abdominal muscles) and posture. Patients with respiratory distress related to airflow obstruction fix their rib cage and shoulder girdle by supporting themselves on straight arms and grasping the sides of their bed.
Ask patient to take a deep breath in through his mouth and then out. Observe for symmetry of chest movement.
Observe for spontaneous coughing. Ask patient to cough and listen to sound (dry or productive?)
Observe contents of any sputum pot, volume of sputum, smell, colour: - yellow/green, flecks of blood, (haemoptysis)
Observe face for colour. Consider if he looks polycythaemic, secondary to chronic lung disease (may have a high colour, red (or “ruddy”) complexion due to overproduction of red blood cells.)
Observe for neurological signs – look in the eyes for Horner’s syndrome (pinpoint pupil and ptosis) – destruction of the sympathetic trunk secondary to apical lung cancer (Pancoast tumour).
Observe mouth. Patients with emphysema may purse their lips on expiration to delay collapse of intrathoracic airways. Look under tongue for central cyanosis.
ASSESSMENT OF HANDS - inspection and palpation
Feel hands to assess circulation, warmth, filling of veins (venodilation). Palpate the nail bed and assess for finger clubbing - one of the signs of hypoxic pulmonary osteoarthropathy (HPOA), along with joint pain. Commoner respiratory causes of HPOA include lung cancer, bronchiectasis (late stages), pulmonary fibrosis, empyema, cystic fibrosis, mesothelioma.Look at hands for cyanotic discolouration of the fingers and evidence of long term smoking e.g. tar staining.
Look for flapping tremor. (CO2 retention). Ask patient to hold hands outstretched with wrists fully extended backwards and fingers spread out. Severe carbon dioxide retention can cause warm hands, a bounding pulse and a coarse irregular flapping tremor at the wrist (the movement is course and jerky). Be sure not to confuse this with a more twitchy tremor that can be caused by liver disease.
Palpate radial pulse and assess rate and rhythm. Assess for a high bounding pulse.
A tachycardia greater than 110 /min in the context of asthma suggests a severe attack.
Count the respiratory rate (observe abdomen or chest, while holding wrist, to avoid alerting patient to your counting, which otherwise might cause him to alter his breathing.) Opinions differ as to what is a normal breathing rate – anything from 16-25 breaths per minute may be considered normal.
Look for Cheyne-Stokes respiration - where tidal volume increases and decreases, interspersed with periods of apnoea (seen in patients with congestive heart failure and those with brain damage).
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4. NECK
A. Check position of trachea.
B. Assess for subcutaneous emphysema if appropriate.
C. Examine for cervical lymphadenopathy.
D. Assess right internal jugular vein for raised JVP.
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NECK
Check position of trachea. It should be central. Place right middle finger 2 cm superior to the suprasternal notch and gently push downwards and backwards and you will feel the resistance of the trachea. Warn patient first that this may cause discomfort. Palpate the space to either side to assess if tracheal is central.Tracheal deviation and displaced apex beat are important signs (fibrosis, (absorption) collapse of lung, pneumonectomy pull trachea towards side of pathology and pneumothorax and pleural effusion push trachea away.)
If history of injury or possible pneumothorax, assess for subcutaneous or “surgical” emphysema. This is a crackling sensation felt on palpating the skin of the neck and chest. The crackling is caused by air under the skin leaking from a pneumothorax or (rarely) a ruptured oesophagus). The neck may also be swollen.
From behind the patient examine the submental, submandibular, and tonsillar lymph nodes and the deep cervical chain of nodes in the anterior triangles of the neck. Examine for scalene node with index or middle finger dipping behind the clavicle. Have sternocleidomastoid relaxed by asking patient to flex head towards side of examination. Enlarged nodes feel firm and rubbery.
Assess JVP. (See notes in cardiovascular examination.) A raised jugular venous pressure may indicate right heart failure secondary to chronic lung disease or pulmonary embolism.
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5. PALPATION OF CHEST
A. Locate the apex beat.
B. Assess chest expansion anteriorly and posteriorly.
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PALPATION OF CHEST
Locate and describe the apex beat. You may not be able to feel the apex beat in patients with a hyperinflated chest. Displacement may provide evidence of mediastinal shift.If history of injury look for seat belt abrasions, flail chest and palpate chest wall gently for tenderness and crepitus (a grinding sensation) over broken ribs.
Assess chest expansion anteriorly and posteriorly by asking the patient to take a deep breath.
Place hands on chest wall with fingers gripping lower ribcage. Bring your thumbs together to meet in the mid-line, but do not let your thumbs rest on the chest wall. Ask patient to take a big breath in and your thumbs should move apart equally. Repeat on the back.
___________________________________________________________________________6. PERCUSSION OF CHEST
A. Percuss front of chest, laterally and posteriorly.
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PERCUSSION
The percussing finger is the middle finger of your right hand. Movement is at the right wrist joint and volume is increased by pushing harder on the chest with the percussed middle finger of your left hand (aim for the middle phalanx).
Percuss the clavicles without your left hand - i.e. use the clavicle as the sounding board for the apices.
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Go back and forth from right to left chest comparing the percussion notes between the two sides (including the clavicles and axillae.) Percussion should be performed over intercostal spaces, moving down the chest at intervals of 3-4 cm comparing both sides. Remember to percuss laterally. Do not percuss over the scapula.
Percuss down to the 6th rib anteriorly, the 8th rib in the axilla and the 10th rib posteriorly.
| Percussion note examples | |
| Normal lung | Resonant |
| Pneumothorax | Hyper resonant |
| Collapse or consolidation | Dull |
| Pleural effusion Abdomen |
“Stony” or very dull Tympanic |
The percussion note is described as stony dull over a pleural effusion, and dull over areas of consolidation, collapse, pleural thickening, or fibrosis. Dullness at the base may be due to a raised diaphragm.
Tactile vocal fremitus is most useful over areas found to be abnormal (both dull and very dull) on percussion. Use your palm or the ulnar border of your right hand. It is conventional in this country to ask the patient to say ninety nine (99). Areas found to be dull to percussion show: -
increased tactile fremitus, suggesting consolidation or fibrosis, or
reduced tactile fremitus, suggesting fluid or collapse.
If an area of dullness is found on percussion you may also wish to test to see if vocal resonance (see below, as it is usually done after initial auscultation, again patient says 99) is:- increased over solid areas for example, consolidation or fibrosis and decreased by fluid or collapse. Compare the voice sound over the dull area to that over normal chest.
Note that vocal fremitus and vocal resonance test the same thing and it is not necessary to test both.
Also please note that some doctors prefer to complete palpation, percussion and auscultation first anteriorly, then move to the back to repeat the sequence of palpation, percussion and auscultation on the back.
Other doctors prefer to palpate anteriorly and posteriorly, then move onto percussion anteriorly and posteriorly and finally auscultate anteriorly and posteriorly. The choice may also depend on the fitness of your patient and his ability to move backwards and forwards.
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7. AUSCULTATION OF CHEST
A. Auscultate front of chest.
B. If areas of dullness on percussion test for vocal resonance or vocal fremitus.
C. Sit patient forwards. Percuss (if not already done) and auscultate posterior chest
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Auscultation
Ask patient to breathe with mouth open and deeply (to increase tidal volume.)Use either the bell or diaphragm. The frequency of breath sounds and added sounds is such that either can be used. If the patient’s chest is particularly hairy, the bell is preferable as it will reduce extraneous scratching sound from hair movement. Also it is preferable to use the bell in the apices to allow good contact.
Auscultate apices in supraclavicular areas with bell.
Auscultate over the front of the chest, axilla and posteriorly with diaphragm or bell.
Once again you are comparing side to side. Make sure that you auscultate over all of the lobes of the lungs.
As you auscultate ask yourself: -
- Are breath sounds present?
- Are breath sounds equal on both sides?
- Are there any added sounds such as crackles, wheezes or pleural rubs?
- Is there any bronchial breathing?
Inspiration is normally longer than expiration (I > E). Breath sounds are produced by turbulent air flow within the smaller and larger airways. They are categorised by the size of the airways that transmit the sounds to the chest wall and your stethoscope. The general rule is, the larger the airway, the louder and higher pitched the sound.
Vesicular (normal) breath sounds, produced by small airways and alveoli, are low pitched quiet and normally heard over most lung fields. The inspiratory component predominates and there is a gap between expiration and inspiration.
Bronchial sounds may be heard in certain pathologies such as when small airways or alveoli have been damaged. They are noises from the larger airways and are harsher. In bronchial breathing the sounds gradually increase through inspiration, but stop near the end of inspiration (when air would normally be flowing round the alveoli.) The expiratory component then dominates. Occurs in consolidation, collapse or fibrosis.
Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (e.g. pneumonia).
Extra lung sounds
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Crackles
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These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (Used to be known as rales). Can be classed as fine, medium or coarse. |
Wheezes
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These are generally high pitched and "musical" in quality. Due to small airway narrowing. |
Friction or pleural rub
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Sounds like creaking leather. Due to pleural inflammation. |
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8. OTHER AREAS
A. Feel for ankle oedema.
B. Look in sputum pot if available.
C. Examine any observation charts available. Pulse, BP, Temperature.
D. Measure peak flow.
9. CONCLUSION
A. Thank patient and wash hands with alcohol gel or water.
B. Summarise and present findings in patient’s notes and orally.
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Abdominal exam
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1. INTRODUCTION
A. Wash hands with alcohol gel or water.
B. Introduce self and seek permission to examine the abdominal system.
C. Confirm patient’s name and date of birth.
D. Ask if patient is currently in any pain or discomfort and ask to point to any area of pain.
E. Position patient supine with one pillow with chest and abdomen adequately exposed.
2. GENERAL INSPECTION
A General (discomfort, distension, colour, muscle wasting, scratch marks, spider naevi)
B. Inspect hands.
C. Inspect eyes.
D. Inspect mouth.
E. Inspect chest and axillae.
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INSPECTION
A. Observe patient generally
for evidence of pain or discomfort abdominal distension, pallor, colour (is he yellow? Jaundice. Does he look anaemic from e.g. bleeding varices/insidious losses/iron malabsorbtion?), muscle wasting, scratch marks, spider naevi and purpura.Purpura is due to spontaneous bleeding into the skin and there are many causes of purpura. One cause may be chronic liver disease and the associated clotting factor deficiencies. (See note about differentiation with spider naevi below.)
B. Inspect both hands
and assess for signs of liver diseaseLook for example for finger clubbing, leuconychia (white nails), koilonychia (also a sign of anaemia), palmar erythema, Dupuytren’s contracture, spider naevi and purpura.
Abdominal causes of clubbing include cirrhosis, ulcerative colitis, Crohn’s disease and coeliac disease.
Palmar erythema is erythema which spares the centre of the palm. It may be due to increased circulating levels of oestrogens (and therefore found in liver disease, pregnancy and the oestrogen contraceptive pill.)
Dupuytren's contracture is a thickening and subsequent contracture of the palmar aponeurosis. The cause of Dupuytren’s contracture is often not known, although it tends to run in families. In most people no specific cause is found, however it tends to be more common in people with cirrhosis of the liver, diabetes, and alcohol dependence.
If there is any evidence of liver disease then look for a flapping tremor as further evidence of liver failure. (Ask patient to hold hands outstretched with wrists extended back and fingers spread out, and observe for a twitchy coarse irregular flapping tremor. Be sure not to confuse this with the tremor of Carbon dioxide retention)
C. Inspect eyes
for xanthelasma (yellowish papules around the eyes indicative of hyperlipidaemia), jaundice, pallor (anaemia)In the context of the abdominal examination xanthalasma around the eyes might suggest prolonged cholestasis in e.g. primary biliary cirrhosis.
The best place to inspect for jaundice is the sclera of the eyes. Pull down the lower eyelid and look at the sclera which is the tough white sheath that forms the outer-layer of the eyeball. It is normally white, but is yellow in jaundice.
When you have pulled down the eyelid take the opportunity to also look at margin of the eyelid, the conjunctiva, for the pallor of anaemia. (The conjunctiva is the thin delicate mucous membrane that covers the front of the eyes and also lines the insides of the eyelids – there should be a definite pink line between eyeball and eyelid.) If there is significant bleeding from the gastrointestinal tract or malabsorption of iron, folate or vitamin B12, anaemia may result. Supporting evidence of anaemia (angular stomatitis and atrophic glossitis) may be found when you go on to examine the mouth and also look at the nails (koilonychia).
D. Inspect mouth
as well as lips, tongue, teeth, gums, breath for pigmentation, telangiectasia, stomatitis and glossitis, ulcers, dentition, gingivitis and odours.Look at lips for pigmentation (the brown freckly pigmentation of Peutz-Jehger’s Syndrome - very rare) and telangiectasia (Hereditary Haemorrhagic Telangiectasia.)
Telangiectasia are red spots or “blebs”, and are actually tiny malformed blood vessels. They are seen particularly on the lips, buccal mucosa, tongue and fingertips. The important point is they may also occur in the gut, lung and nose and cause severe bleeding.
Look at the open mouth for stomatitis and glossitis as evidence of iron deficiency anaemia. Angular stomatitis can occur due to candidal infection or chronic anaemia.
Look in the mouth at the buccal mucosa and tongue (including underside of tongue for telangiectasia), for telangiectasia, ulcers, pigmentation and candidiasis (whitish plaques).
Aphthous ulcers are common and painful, herpetic ulcers may occur in crops and a painless non healing ulcer should alert you to squamous cell carcinoma.
Check the state of the gums and teeth.
Check breath for odours (e.g. alcohol, the acetone smell of ketosis or the musty smell of hepatic failure).
Visualise the tonsils if present.
Look for signs on the tongue – wasting due to neurological problems or an enlargement due to hypothyroidism, acromegaly or 1° amyloidosis.
Check for normal swallowing.
E. Inspect chest and axillae.
Inspect chest for spider naevi, gynaecomastia in men, and axillae for loss of axillary body hairGynaecomastia and loss of axillary hair in men: Chronic liver disease may result in feminization of the male due to increased circulating oestrogens and decreased testosterone, although this can also be a side effect of numerous drugs.
Spider naevi are telangiectasia and are most commonly found on the face and the anterior chest wall. They comprise a central arteriole which feeds tiny radiation vessels. (Looks like a spider.) If you press on the centre it will blanch. On removing your finger you will then see the blood refill the “legs of the spider”. One or two spider naevi may occur in normal people, thyrotoxicosis and pregnancy. If more than 5 are present they are considered significant and likely to be due to chronic liver disease. (By contrast when pressure is applied to purpura the spots do not blanch.)
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3. INSPECTION OF ABDOMEN
A. Inspect for movement, distension, scars, herniae, masses, dilated veins and abnormal pulsations.
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Inspection of Abdomen
With imaginary lines, divide the abdomen visually into 9 regions to assist with any description. You do not need to be exact, but the two vertical lines used are the mid-clavicular lines and the two horizontal lines are a line at a level halfway between xiphisternum and umbilicus and the transtubercular plane.Right Hypochondrium |
Epigastrium |
Left Hypochondrium |
Right Lumbar |
Umbilical |
Left Lumbar |
Right Iliac Fossa |
Suprapubic or (hypogastric) |
Left Iliac Fossa |
Abdominal wall contour and movement:-
Look at abdomen to check that it is symmetrical and moves gently out on inspiration. Look for visible peristalsis (an abnormal sign). If the patient has peritonitis and abdominal rigidity there will be no visible movement with respiration. Crouching down and ‘skylining’ the abdomen is a good idea.Look for distension. The causes of a swollen abdomen may be conveniently remembered by the “five F’s”:-
Fluid, flatus, fat, foetus, and faeces
Look for abdominal herniae - localised bulges which occur in areas of weakness of the abdominal wall. If a hernia is visible ask the patient to cough or sit up and the bulging will increase with the rise in intra-abdominal pressure.
Examples of herniae:
- Epigastric – through midline
- Umbilical – localized to navel
- Paraumbilical – just above/below umbilicus
- Direct/indirect inguinal
- Femoral
Striae are stretch marks e.g. caused following stretching by pregnancy or obesity. One important medical cause of striae is Cushing's Syndrome – these striae tend to be reddy-purple in colour and more substantial.
Distended veins may be present in portal hypertension in chronic liver disease, and in inferior vena cava obstruction. ‘Milking’ the vein can show the direction of blood flow.
Pulsations in the abdomen are usually due to the abdominal aorta and are normally seen in thin patients.
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4. PALPATION OF ABDOMEN FOR ORGANS AND MASSES
A. Superficial palpation in each of the 9 regions beginning away from any area of pain.
(Palpate for rigidity, tenderness, guarding, rebound and masses whilst observing face.)
B. Deep palpation
Repeat sequence with deeper palpation throughout the 9 regions and assess any masses felt
Palpate for liver, spleen, ballot for enlargement of kidneys and palpate abdominal aorta.
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Palpation of Abdomen
Position your patient lying flat, with one pillow under head and with adequate exposure of the abdomen. Try to make sure that room is warm and patient is as relaxed as possible with his hands at his side. If necessary ask patient to flex knees to relax abdomen.Examiners position: crouch or kneel beside the patient. It is important to have warm hands.
Ask patient to point to any areas of tenderness or pain. Start examination away from site of any tenderness or pain. Examine the nine regions systematically (usually clockwise) finishing with umbilical region.
There are 2 types of palpation: - Superficial and Deep Palpation
Superficial Palpation
This is l ight palpation:- using the pulps of your fingers, bending fingers at knuckles (MCP joint). Do not use finger tips. Move (roll) your hand over abdomen keeping contact with the abdomen. Ask patient to tell you if it is tender when you press. Look at the patient’s face while you examine for evidence of tenderness or pain. Assess any tender areas for guarding and rebound tenderness. Guarding is instantaneous contraction of muscle over an inflamed organ or peritoneum. Rebound tenderness is another sign of an inflamed peritoneum. Pain is experienced after quickly lifting your hand off the affected area.Deep Palpation
Repeat the sequence with deep firmer (or bimanual palpation) in the 9 regions. Assess with deep palpation any abnormal masses found on light palpation.Palpate for enlarged organs
Then perform deep (respiratory) palpation for liver, spleen and kidneys. (Liver is not normally palpable but may just be palpable in very thin normal subjects. Sometimes the lower pole of the right kidney is just felt in normal subjects.)
Liver
Start examination in right iliac fossa (RIF) and move towards the right costal margin asking patient to take deep breaths in and out. Use tips of 2nd and 3rd right fingers (or radial side of right index finger if you prefer) to feel for the liver edge. Move your hand up with each expiration.
(Note that on inspiration the liver moves down in the abdomen, and this may assist you in feeling the liver edge in an enlarged liver.)
Spleen (stand to examine the spleen)
Perform a similar palpation for an enlarged spleen. Again, start in right iliac fossa (to avoid missing a very large spleen) and perform respiratory palpation moving towards the left costal margin.
Kidneys using a bimanual technique in the flanks ballot for kidneys bilaterally. Finally palpate abdominal aorta.
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5. PERCUSSION OF ABDOMEN
A. Percuss for liver.
B. Percuss for spleen.
C. Percuss flanks for dullness and demonstrate shifting dullness or fluid thrill (palpation) if appropriate.
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Percussion of Abdomen
The percussing finger is the middle finger of your right hand. Movement is at the right wrist joint and volume is increased by pushing harder on the abdomen with the percussed middle finger of your left hand.| Percussion note examples | |
| Gas filled structures (bowel) | Resonant |
| Solid organs | Dull |
| Distension (flatus) | Tympanic (hyper resonant) |
| Fluid (ascites) | Dull in flanks and shifts when roll |
The liver is dull to percussion therefore first percuss below the liver in an area that should be resonant. Percuss upwards until the note becomes dull. Then percuss for the upper margin (which is usually in the 6th intercostal space), beginning just above the right nipple and percuss downwards. The resonant note should become dull in the 6th interspace.
Percuss upwards in the left hypochondrium for the lower border of spleen, beginning in an area where the percussion note should be resonant.
Percuss in flanks. The percussion note should be resonant. If dull it suggests fluid and you would then go on to demonstrate shifting dullness on percussion by asking patient to roll over towards you onto his side. Percuss again in the right flank and the note should now have become resonant as the fluid moves.
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6. AUSCULTATION
A. Auscultate for bowel sounds and abdominal aorta bruit.
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Auscultation
Auscultate the abdomen, listening for bowel sounds, which are normally gurgling sounds. If you do not immediately hear bowel sounds you may have to listen for up to one minute. Absent bowel sounds suggest a paralytic ileus or, if the abdomen is rigid, peritonitis. Tinkling bowel sounds suggest an obstruction.___________________________________________________________________________
7. SIT PATIENT FORWARD
A. Inspect back.
B. Palpate for renal tenderness.
C. Auscultate for renal bruits.
E. Palpate neck for cervical lymphadenopathy.
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Inspect back for renal scars.
Palpate for renal tenderness in loins.
Auscultate for renal bruits on either side of midline.
While sitting patient forward, complete the examination by palpating neck for lymphadenopathy.
From behind the patient
Use your index, middle and ring fingers together to gently palpate both supraclavicular fossae. Troisier's sign is the finding of a palpable left supraclavicular lymph node.
Tumours of chest and abdomen usually metastasise to the lower part of the left posterior triangle deeply in the angle between the sternocleidomastoid and clavicle. Lymph drains from the gut to this node. A palpable node (sometimes called Virchow's node) may indicate gastrointestinal malignancy, commonly of the stomach (but remember it could possibly be lung cancer.)
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8. OTHER AREAS
A. Inspect and examine groin for hernias and lymphadenopathy.
B. Examine external genitalia.
C. Perform digital rectal examination.
D. If appropriate palpate and percuss for distended bladder.
9. CONCLUSION
A. Look at observation charts and test urine with dipstix.
B. Thank patient and wash hands with alcohol gel or water.
C. Summarise and present findings in patient’s notes and orally.
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