- Greet examiner and thank them
- Position briefcase on safe bench and open it
- Take out stethoscope and place around neck
- note college does not allow electronically augmented stetoscopes unless medically cleared
- Wash hands
- Introduce yourself and shake the patient's hand (gain evidence about weakness)
- Standardised way: Hello Mr/Mrs ... My name is Dr ... Thank you for letting me examine you today
- Position patient
- Make sure bed is at 45 degrees
- Expose chest wall
- If female re-cover with towel or apron until palpation and auscultation is required
- Make a general examination of appearance by...
- standing back and looking for equipment (eg oxygen, IV lines, infusions such as flucloxacillin in a patient with MSSA endocarditis)
- standing back and observing patient (de mussett's sign of head nodding in aortic stenosis). Other signs include marfinoid habitus, arachnodactyly
- Examine both hands
- start at nails --> splinters for signs of infective endocarditis
- examine for clubbing --> shammroth's sign, palpate nail bed, look sidewards at nails
- Examine both palms
- Osler's nodes
- Janeway lesions
- Palpate the right radial artery
- Note volume (low, bounding)
- Character (slow rising, bisferens, collapsing)
- Rhythm (irregular)
- Rate --> feel for 15s (and multiply pulse x 4)
- Palpate for radio-radial delay
- Ask to palpate the femoral pulse
- Is it ok if I can feel the pulse in your groin?
- Palpate for radio-femoral delay
- Palpate for bracho-radial delay
- Ask the patient if their shoulder is sore
- Raise the arm whilst palpating the radial artery
- Examine for the water-hammer sign of aortic regurgitation
- Measure the patient's blood pressure
- Repeat the blood pressure out loud
- Ask the examiner for temperature and saturations and repeat it back (so you remember them)
- Examine the patient's eyes
- Can you please look upwards
- Examine their conjunctiva for signs of anaemia (infective endocarditis, Heye's syndrome, intravascular haemolysis associated with a prosthetic valve)
- Note xantholesma arcus senilis, evience of lens dislocation, blue sclera
- Examine the patients mouth with a pen torch
- Can you please open your mouth
- Look for central cyanosis, high arched palate, poor dentition, ulcers
- Look for JVP by turning the patients head slightly away from you
- Use a pen torch if lighting allows tangentially
- Look for double flicker
- Look closely for the loss of 'a' waves in atrial fibrillation and the systolic 'v' waves
- Measure the venous pressure vertically from the sternal angle
- Attempt to occlude the venous pressure and observe for loss of double flicker and venous filling
- Are you tender anywhere in the abdomen Mr/ Mrs X?
- Elicit the hepato-abdominal reflex by pressing gently on the liver, feel for signs of pulsatile liver at the same time
- Look and palpate the carotid arteries
- Elicit the dancing carotid sign (Corrigan's sign) of aortic regurgitation by tracing the visible carotid impulse and proving that it does not occlude
- Palpate the carotid pulse with the right hand (first right then left carotid artery of patient)
- Auscultate with bell (apply low pressure on stethoscope without bell)
- Expose the precordium in females (the males precordium should have already been exposed)
- Inspect chest wall thoroughly
- Look for obvious deformities - eg
- Feel for devices (pacemaker box, AICD, CRT-D)
- Tract the midline sternotomy scar, or the hemisternotomy scar with the right index finger
- Tract the mitral valvotomy scar in the left lateral chest with the right index finger
- Trace the radial artery harvest scar with the right index finger
- Trace the saphenous vein harvest scar with the right index finger
- Measure out and locate the apex beat
- Measure rib spaces down
- Measure displacement laterally (MR, HOCM, AR, dilated cardiomyopathy)
- Palpate for tapping apex beat of MS
- Palpate for heaving apex beat of AS
- Palpate for thrusting apex beat of MR and AR
- Palpate the left sternal edge
- Use right hand vertically
- Palpate for right ventricular heave
- Use right hand horizontally across the sternum, with fingers in the pulmonary area
- Palpate for P2
- Palpate the aortic area
- Right hand right sternal edge, second interspace
- Palpate for aortic thrill
- Auscultate at the Apex
- Use the diaphragm and bell of the stethoscope and note the following information
- S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
- Take a big breath in and hold it for me please?
- Can you take a breath out for me and hold it please?
- Use the diaphragm and bell of the stethoscope and note the following information
- Role the patient to left lateral position
- Can you please role slightly to your left side
- Palpate the apex beat again
- Use the diaphragm and bell and note the following information
- S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
- Can you hold you breath in for me please?
- Can you take a breath out for me and hold it please?
- Role the patient onto the back
- Can you please roll on to your back again? Thank you.
- Auscultate over the axilla for radiation of MR (or AS)
- Auscultate over tricuspid area with the diaphragm and note the following information
- S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
- Can you hold you breath in for me please?
- Can you take a breath out for me and hold it please?
- TR gets louder on inspiration
- Auscultate over the left sternal edge (VSD, AR)
- Auscultate over the pulmonary area (PR, PS)
- Auscultate over the aortic area (AS)
- Sit the patient forward
- Please sit forward for me
- Feel for an aortic thrill
- Auscultate over the aortic area with the diaphragm and note the following information
- S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
- Can you hold you breath in for me please?
- Can you take a breath out for me and hold it please?
- Auscultate over the LSE and RSE for AR
- If you have determined the presence of a systolic murmur perform the valsava as follows
- Can you please pinch your nose
- Take a big breath in and...
- Try and unblock your nose
- Sit the patient forwards again
- Percuss for an effusion from the top of the lungs posteriorly down to the bottom
- Auscultate for an effusion quickly
- Palpate for sacral oedema
- Palpate for pitting oedema
- Lie the patient flat in bed and palpate for hepatomegaly
- Start at the right iliac fossa and move upwards whilst asking the patient to take big breaths in and out
- Repeat the following statement to complete the examination
- I would like to complete my examination by performing fundoscopy, perform a urinalysis and a bedside ECG