Once you have done your initial introductions and examination from the end of the bed described in the examinations page you can then move onto more specific examination.
Now we can approach the patient and start to take a good close look at them. As with both abdominal and respiratory examination we always start with the patients hands. As well as just looking one can also tell a lot from the feel of those hands:
- Are they warm or cold? A cold septic patient is often a sicker one than a warm septic patient.
- If they are cold do they appear peripherally shut down? Are their hands mottled looking? What is their capillary refill time?
- Do they feel sweaty or clammy?
- Do their hands appear pale or anaemic looking?
- Are there any signs of a chronic smoking habit i.e. nicotine staining around the fingers.
- Are their finger nails clubbed? Always hold the hands up to eye level if possible or get down to their level to look at the nails side on which is the best angle from which to judge nail clubbing.
We then move our examination up the arm. I always make a point of looking at the arm as I move up so that I do not forget anything. At this stage we need to check the radial pulse and we are checking it for presence, rate, rhythm and volume. A very tachycardic patient may be septic, or it could just be the drugs which we give them which are making their heart beat faster. A patient with a bounding pulse may be showing early signs of carbon dioxide retention. As with all systems when you have two of something you should always compare and contrast. So you should check the other hand to see if there are any differences and you should compare the radial pulses on both sides. We are assessing the pulses for rate, rhythm and volume and you may also check for a collapsing pulse by lifting the patients arm into the air whilst still palpating the pulse to see if their is a change in the volume of the pulse. This may indicate a degree of aortic regurgitation if present.
As you move up the arm this is a good point to check the patients blood pressure. Is it within a normal range or is there a problem with it. It may be worth assessing whether it is the same in both arms, especially if there is a suspicion of any aortic disease.
When you move up to observe the neck you should try to assess the height of the Jugular venous pressure.
The patient should ideally be at an angle of 45 degrees and with their head turned slightly away from you. First find the sternocleidomastoid and identify the clavicular head and the sternal heads of that structure. Having done so one may be able to see the JVP within this triangle. If you can see it then you should remark on it and try to estimate its height above the angle of Louis.
Whilst examining the neck you should also then asses the carotid pulse for volume and character.
The examination of the face can start more specifically by looking at the patients eyes:
- Is there any evidence of xanthalasma which may indicate hypercholestolaemia.
- Corneal arcus which might suggest hyperlipademia.
- Conjunctival pallor which may suggest aneamia. Be aware that the conjunctiva is normally pale in its posterior part but the anterior aspect should be normally red in appearance.
Examination of the mouth and tongue may be suggestive of central cyanosis of the tongue appears blueish in colour. Does the patient appear dehydrated with dry mucous membranes? Is there any evidence of poor dentition which might lead one to suspect that infective endocarditis may be a problem?
The process of inspection, palpation and auscultation can now begin. Inspection of the chest would be looking for things like scars, sinuses, any obvious lumps e.g. a pacemaker box by the left shoulder. It is also important to note their inspiratory rate and effort at this point.
Then one needs to palpate for the apex beat. This involves laying the flat hand on the patient’s chest just below their left nipple and the apex beat should be located approximately at the mid clavicular line at the 5th intercostal space. If it has moved more laterally than this then this could be due to enlargement of the heart. One then need to palpate the areas on the skin which relate to the valves in order to assess for any thrills or heaves which may indicate valvular disease. A heave will almost lift your hand off the surface, whereas a thrill is often likened to having a ringing telephone under ones hand.
You then will go onto assess the heart sounds for any disorders.
It is important when doing so to be aware of a number of things to understand what one is listening to:
- The lub-dup is caused by heart valves closing.
- Lub precedes systole.
- Dup precedes diastole.
- Stenosis of valve causes a hardening of the valve and makes it reluctant to open and close easily.
- Regurgitation of the valve turns a one way valve into a two way valve and allows some back flow of blood where there shouldn’t be any.
Aortic stenosis is one of the more common valve problems.
The valve is struggling to open when it should, and this valve tries to open in systole to let the blood flow from the left ventricle and into the aorta. As a consequence the sound caused by the turbulent blood flow created is heard during systole, or after ‘Lub’. It is described as a ejection systolic murmur.
It will be best heard at the 2nd-3rd intercostal space just lateral to the sternal border.
Regurgitation will often occur when the valve is trying to close. It has become incompetent for some reason and so allows some blood flow the wrong way. This creates another sound. In the case of the aortic valve this sound will be heard in diastole as this is when it is trying to close.
The blood has moved out of the left ventricle and into the aorta and the lower pressure on the ventricle side and the higher pressure on the aortic side combine to close the valve. So aortic regurgitation is heard as a softer blowing sound at the start of diastole. It can be heard best with the patient leaning slightly forward.
On the same side of the heart is the mitral valve, sitting between the left atrium and left ventricle. This valve is open when the aortic valve is closed and vice versa. It follows then that the sound of mitral regurgitation will be heard during systole, especially if one remembers that this is when this valve is trying to stay closed to stop blood flowing back into the atrium.
Mitral valve regurgitation is a sound which is pan-systolic and is heard best over the apex of the heart which is located normally just below or slightly laterally to the left nipple. When trying to hear this sound it is also best to listen with the bell lightly applied rather than the diaphragm.
There are many more different heart sounds which may be heard. The ones I have mentioned above are just the start. When first starting to listen to heart sounds you should consider the following things when doing so:
- Always time the heart sounds with what you can feel by palpating the carotid at the same time.
- Can you distinguish ‘lub’ from ‘dup’ or S1 from S2?
- If you can are there any added sounds between these two.
- If there are, where are those sounds heard best? You will need to move your stethoscope around to the various areas to ascertain where they are loudest, which then gives you clues as to which valve is involved.
There are many resources out there, in books and on the web for you to listen to various heart sounds. Dr Eric Strong is a Hospitalist and Assistant Professor of Medicine at Stanford University. He has made a series of excellent video tutorials on a variety of subjects, all of which are well worth watching. His You Tube channel can be found by clicking here or on the link to the right.
Do you need some help to remember all this information? Are you about to take an OSCE to examine your skills in Clinical Examination? Maybe you will find the Audio files I have created to help you revise the OSCE process helpful?