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    General Inspection:

    • Introduction/privacy/consent/wash hands/name & age of patient/asks patient for sites of pain before commencing:

    • Performs a general inspection:

      • Comments that patient is comfortable at rest, on anyevidence of distress/ pain

      • Describes peripheral perfusion with comments on any evidence of cyanosis

      • Comments on obvious scars

    • Hands:

      • Student assesses temperature of both sides. Assess whether cold and clammy, peripherally perfused (cyanosis), comments on capillary refill (2 secs), with additional comments on peripheral stigmata of endocarditis or anaemia

      • Assesses pulse: Rate, rhythm, character (brachial or radial via Waterhammer pulse). Compares with opposite side for radio-radial delay (subclavian stenosis) and radio-femoral delay (coarctation of aorta)

      • Offers to perform BP

    • Neck:

      • Check carotid pulse for aortic stenosis (slow rising pulse)

      • Student asks patient to lie at 45 degrees to assess the JVP. This is then determined as the vertical (perpendicular) distance from a ruler moving from the angle of Louis to the double wave form of the JVP

    • Face:

      • Student check eyes for xanthalesma (eyelids), corneal arcus (hyperlipidaemia) and anaemia. Comments on any evidence of a Malar flush associated with mitral stenosis

    • Mouth:

      • Assesses for anaemia (cheilitis & stomatitis), central cyanosis, mucosal hydration & palate (Marfan's syndrome - high arch palate)

    • Chest:

      • Checks for any obvious scarring (median sternotomy) from previous surgery, and any visible heaves or thrills


    • Performs a general palpation around the precordium to gain a general consensus of the cardiac activity

    • Checks first for apex beat (4th-5th intercostal space, mid-axillary line): Is there shifting from LV dilatation? In the presence of displacement, localise, and also check for tracheal deviation. A tracheal deviation can be associated with a mediastinal mass, tension pneumothorax or left sided lung collapse

    • Assesses RV heave by placing palm on left sternal edge

    Auscultation (NB percussion not generally used):

    • Checks apex region for mitral pathology, then shifting patient to left side for mitral stenosis (asks patient to breath in, out and hold). Bell is used for this region, with radiation to the axilla assessed for presence of mitral regurgitation

    • Checks left lower sternal edge for tricuspid area

    • Checks 2nd intercostal space, left sternal edge for pulmonary area

    • Checks 2nd intercostal space, right sternal edge for aortic area

    • Auscultate lung bases for pulmonary oedema associated with LHF, and assess back for sacral oedema

    • Finishes by checking for pitting oedema in the legs, hepatosplenomegaly, fundoscopy, urine dipstick (endocarditis)

    Thanks patient & documents findings in the notes:

Author: Mr Adnan Darr MBCHB, BSc, MSc, MRCS  | Speciality: Examination  | Date Added: 11/10/2011


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