6) “Osler nodes”(painful, raised < 1.5 cm on soles and plantar surface)
7) Capillary refill: “Mr./Ms…., I’m going to squeeze your thumb”press on nail bed & release while looking on your watch:
< 3 sec.
To the examiner“Capillary refill is normal less than 3 sec”
2- Face:
To the examiner“There is / is no…” while inspecting: CSM+ Eyes (X CSF) 1. Colour:
1) “Plethora”(pink),
2) “Jaundice”(while looking on the sclera),
3) “Central Cyanosis”Central: blue lips & buccal mucosa: SO2< 80%
4) “Pallor”.
2. Shape:
1) “Cushinoid / moon face”(round, puffy). 2) “No Myosis, ptosis”(Horner Syndrome)
3) “No Mitral face”(Red cheeks in mitral stenosis)
3. Mouth: “No pursed lips”(emphysema).
4. Eyes: “Mr./Ms.., let me examine your eyes.”
1) “No Xantholasma”yellow lipid deposition on upper and lower eyes’
lids.
2) “No Senile arcus” yellow lipid deposition in cornea at its margins with conjunctiva.
3) “No Conjunctival hemorrhages”.
4) Fundoscopy: “Now, with this scope.” (examiner will stop you). Look for: 1- “Copper wires”.
2- “Soft / hard exudates”.
3- “Roth spots”: erythmatous lumps 4- “Emboli in retinal arteries”.
3- Neck: Jugular Venous Pressure (JVP):
JVP is a direct assessment of central venous pressure (RA pressure).
1- JVP Height: “Mr./Ms…., now, I’ll do some measurement on your neck. I’ll put your head higher. Is that okay?”
- Position the patient at 30oand ask the patient to turn his head slightly to the left. Then adjust the elevation up to 45ountil pulsations are seen.
- Look between the two heads of the sternocleidomastoid muscle (at sternal head of clavicle) for pulsations. If difficult, shine a light tangentially across the right side of the neck and look for shadows of pulsations.
- Determine JVP by measuring the vertical distance from the sternal angle to a horizontal line from the top of the jugular pulsations.
2- Waveform: Normally double waveform.
3- Kussmaul sign: Only if JVP is high.
“Mr./Ms…., take a deep breath.”
…Continued
99 The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
4- Hepatojugular reflex (HJR): Only if JVP is high.
- To assess that high JVP is due to RV function and not SVC obstruction.
- Let the patient breath quietly from his mouth. “Mr./Ms…., breath normally from your mouth, please”. “I’m going to push on your stomach here for a while.”
- Apply moderate pressure over the liver at the RUQ with your hand
& sustain it for 10 sec.
- A sustained elevation of the JVP height for > 4 cm for 10 sec is pathological.
“Mr./Ms…., I’ll put your head down.”
To the examiner“No JVP/ is normal double wave at .. cm/ High at ... cm, +ve Kussmaul”
4- Chest:
“Mr./Ms…., I’m going to uncover your chest.”
Uncover the chest. Look anteriorly & posteriorly.
To the examiner“The chest is/ There is …” while inspecting: CSSP 1. Contour: “Symmetric / not”.Normally AP diameter < lateral diameter
(eye-balling).
2. Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest. No Kyphosis or scoliosis.”
3. Skin: “No Surgical scars or dilated veins.”
“No intercostal retraction”.
4. Precordial pulsation. “No Precordial pulsation.”
4-
Palpation:
Warm up your hands.“Now, Mr./Ms…., I’m going to feel your chest”
1- Areas of tenderness: Compress the chest from side to side and front to back for tenderness “Any pain?”
To the examiner“There is / is no areas of tenderness”
“Mr./Ms…., lie down please.”
2- Abnormal pulsations: at 5 areas: Apex, RT & LT 2ndICS, LLSB, RLSB.
1- Palpable heart sounds: S1 in MS, P2 in PA pulsation, S3, S4 2- Heaves: use your finger pads.
3- Lifts: (in LT parasternal area): use your finger pads. RVH, LAE, severe LVH.
4- Thrills (palpable murmur of loud intensity >3/6): use the heel of your hand.
5- Implanted pacemakers/ defibrillators. (Inferior to left clavicle) 6- Epigastric pulsations: RVH in COPD.
To the examiner“There is/ is no palpable heart sounds, heaves, thrills, lifts, Epigastric pulsations, or implanted
devices” ... Continued
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
3- PMI (Point of Maximum Impulse):
Indicates LV size. Palpate in supine but better felt in LLD. Describe it as LDAD:
1- Location: SUPINE: Normally 5thICS, mid clavicular line. Otherwise displaced or cardiomyopathy if lateral/inferior to that. (Children <7 years old: 4thICS)
2- Diameter: Normally 2-3 cm. Abnormal if > 3 cm or diffuse : LVH.
3- Amplitude: - Exaggerated: Volume or pressure overload.
4- Duration: =< 2/3 of systole. Check with radial pulse.
- Sustained (increased): LVH.
- Brief: AR, MR, and LT to RT Shunt.
- Morphology: Double/triple impulse: HCCM.
To the examiner“PMI is 2 cm at the 5th ICS MCL (while holding radial pulse), single impulse of normal amplitude & duration.”
5- Percussion:
Not useful but do it.- Increased cardiac dullness: Pericardial effusion.
- Decreased cardiac dullness: COPD.
To the examiner“Cardiac dullness is …..”
6-
Auscultation:
Warm the stethoscope.“Mr./Ms. …, now, I’m going to listen to your heart.”
- Listen over 5 areas: Apex, Lt & Rt 2ndICS, LLSB, and RLSB.
- Listen over all these 5 areas in 4 positions:
1- Supine: (USING THE DIAPHRAGM SIDE): For S1(best at apex),S2 &
S2 Splitting (A2 & P2)(best at pulmonary), and murmurs.
2- LLD: “Mr./Ms. …, Will you please turn half way on your side away from me.”(USING THE BELL SIDE): For S3 & S4.(best at apex)
3- Upright: “Mr./Ms. …, Will you please sit up”
(USING THE DIAPHRAGM SIDE): Listen to the five areas.
4- Forward upright: “Mr./Ms. …, could you lean forward, please.”
(USING THE DIAPHRAGM SIDE):
1.“Take deep breaths in and out.” Listen to the five areas.
2.“Take a deep breath in and hold it.” Listen to apex and LLSB only.
3.“Take a deep breath in and out and hold.” Listen to apex and LLSB only.
- Lungs: As the patient is sitting now: listen to the lung bases for crackles.
“Now, I’ll listen to your lungs at the back. Take deep breaths in and out.” Listen to lung bases at the back.
- Murmurs: If present comment on:
1- Timing: Systolic, diastolic, continuous.
2- Shape: Crescendo, decrescendo, crescendo-decrescendo, plateau.
3- Quality: Blowing, harsh, rumbling, musical, machinery, scratchy.
4- Location: of maximum intensity.
5- Radiation: Axilla, back, neck. … Continued
101 The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
6- Duration:
7- Intensity: out of 6. (not an indication of clinical severity) 8- Pitch: High, medium, low.
9- Relationship to respiration.
10- Special maneuvers.
To the examiner“Heart sounds are normal/…, no S3, S4, no murmurs.
Chest is clear.”
Note: 80 % of children have innocent murmurs: Systolic, short duration, low pitched, <grade 3, vibratory, change with body position change.
7- Peripheral edema:
As the patient is still sitting now, check for:
- Sacral edema: Press against sacrum.
- Ankle edema: Press against the tibia bilaterally.
“Mr/Ms…, I am going to push on your lower back…. Now your legs.”
To the examiner“There is /is not … pitting or non-pitting edema.”
8-
Peripheral bruit:
Auscultate with the bell.1. Carotid bruit. “Mr/Ms…, I am going to listen to the blood flow in your neck.”
2. Abdominal Aorta. “Now, the blood flow in your belly. Lie down please.”
3. Renal arteries: 5 cm above the umbilicus and 5 cm to either side from the midline.
4. Iliac arteries. Below the umbilicus on both sides.
5. Femoral arteries. “Now, the blood flow in your groins.”
To the examiner “There is /is not …carotid, aortic, renal, iliac, or femoral bruits.” Mention it as you are examining related area.
9-
Peripheral pulses:
“Mr/Ms .., I am going to feel your pulses”
Look for: 1. Rate; 2. Rhythm; 3. Contour; 4. Amplitude (volume);
5. Symmetry.
1- Radial pulses: Both at the same time and count for 30 sec.
“Will you please give me both your arms.”
To the examiner“(rate)The pulse is …bpm,(Rhythm)regular/ regularly irregular/ irregularly irregular, (Contour)Normal / rapid/ slow rise pulse, (Amplitude)absent/ weak/
bounding pulse,(symmetry)same volume bilaterally and symmetrical timing.”
2- Carotid pulse: If there was no bruit heard, no need. One at a time, never together.
“Mr/Ms…, I am going to feel the pulse in your neck.”
To the examiner“As I heard no bruit, there is no need for palpating the carotids / The carotid pulses are normal/weak.” … Continued
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
3- Aorta: Mid line above the umbilicus. “Now, the pulses in your belly.”
To the examiner“The aortic pulse is normal/ weak, no pulsating mass.”
4- Femoral pulses: Both at the same time. “Now, the pulse in both your groins.”
- Radio-femoral delay: One side only. Feel both: an arm and a femoral pulse together.
To the examiner“The femoral pulses are of the same volume bilaterally and there is no radio-femoral delay.”
5- Popliteal pulses: “Now the pulse behind your right knee, relax it”
Check the pulse with both your hands’ fingers under the knee at the same time holding the leg with the thumbs at the sides while lifting the
knee10-20o
“Now, relax the left knee.” Repeat.
To the examiner“The popliteal pulses are normal/weak.”
6- Posterior Tibials: “Now, I’ll feel your feet.”
Palpate behind and slightly below the medial maleolus. Both legs at the same time with both your hand fingers.
To the examiner“The posterior tibial pulses are normal/weak.”
7- Dorsalis pedis:
Palpate the dorsum of the foot at the lateral to the extensor tendon of the big toe. Both legs at the same time with both your hand fingers.
To the examiner“The dorsalis pedis pulses are normal/weak/absent.”
COVER THE PATIENT END …Wrap up
103