This is a draft cheat sheet. It is a work in progress and is not finished yet.
Preperation:
W |
Wash Hands |
I |
Introduce Yourself + Patient's Identity |
P |
Permission |
P |
Patient Position + Pain |
E |
Explaination |
Patient must be placed at 45°
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General Inspection:
Check visually from the end of the bed:
• Discomfort at rest
• Tachypnoea
• Pallor
• Cyanosis
• Surgical Scars
• Medical paraphernalia (e.g. IV infusions)
• Consciousness |
Examination of Hands:
Clubbing: |
Place 2 fingernails together and look for Schamroth's sign |
Chronic low blood-oxygen levels |
Pale Creases |
Peripheral Cyanosis |
Nicotine Staining |
Splinter haemorrhages: |
Small red lines on fingernails that look like a splinter |
Tiny clots that damage small capillaries under the nails |
Lesions on fingers: |
Tender -> Osler's Lesion
(O for ouch))
Not tender -> Janeway's Lesion |
Endocarditis |
Vitals:
Capillary Refill: |
N<2secs |
Radial Pulse: |
Identify rate and rhythm
Allow for at least 15 sec |
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Compare both radial pulses for evidence of radial delay. |
Mention checking for radial-femoral delay. |
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Examine for collapsing pulse |
Quickly raise patient's arm above their head while measuring their pulse. |
Brachial pulse: |
Both arms |
Femoral pulse: |
Indicated if difficulty finding radial/brachial pulse |
Breathing Rate: |
Should be examined immedately after taking radial pulse without informing the patient |
Blood Pressure: |
Should be measured in both the right and left arms, standing and supine. |
For DEM2 you only need to offer to check BP. |
Examination of the Face:
Malar Flush: |
Plum-red discolouration of the high cheeks |
Associated with mitral valve stenosis due to the resulting CO2 retention and its vasodilatory effects |
Examination of Eyes:
Anaemia: |
Pale conjunctiva |
Corneal Arcus: |
Lipid deposits that appear as rings on the outer region of the cornea |
Xanthelasma of hypercholesterolaemia: |
Pale yellow lump near eyelid |
Examination using fundoscopy should be done in patients with a history of diabetes, hypertension, or endocarditis
Examination of the Mouth:
Dental Hygiene: |
Possible cause of bacterial endocarditis |
Central Cyanosis: |
Examine for blue tongue |
Pulses:
Jugular venous pulse: |
Located between the 2 heads of the SCM. Measured as cm of water above the sternal angle.
Must remember to add 5cm to measured distance above sternal angle.
Difficult to see, may require the use of a torch, abdomino-jugulo reflux can exaggerate the JVP in right sided heart failure. |
Patient must be placed at 45° |
Carotid pulse: |
Examine both, however only one at a time to avoid the patient feeling faint.
Comment on character and volume |
In patients over 50 you should listen for carotid bruits first. |
Chest Inspection:
Surgical scars, lift any fat/breast to check under |
Check for any pacemaker, etc. |
Visible apical pulsation |
Audible prosthetic heart valve |
Physically feel for the heart at apex |
Normally 5th intercostal space, left midclavicular line |
Palpate for heaves (using heel of hand) and thrills (finger pads) |
Chest Auscultation:
Begin at the apex (Mitral Area) and proceed towards the base of the heart.
Must be repeated with both diaphragm and bell. |
S1 |
Caused by the closing of the atrioventricular valves after blood has been pumped into the ventricles. |
S2 |
Caused by the closing of the aortic and pulmonary valves after the ventricles have contracted. |
S3, S4 |
Third heart sound can be normal (in a younger patient)
Fourth heart sound is always abnormal |
Check for radiation to carotid or axilla. |
Carotid bruits: |
Whooshing sound in the carotid, caused by non-laminar blood flow. |
Patient should be manouvered to accentuate murmurs:
Forward in expiration for aortic regurgitation.
Left lateral position in expiration for mitral murmurs. |
Heart sounds should be timed by palpating pulse while auscultating.
The interval between S1 and S2 is systole.
The interval between S2 and the next S1 is when the ventricles relax and are filled with blood, i.e. diastole.
Back of Chest:
Inspect chest wall for deformities/incisions |
Palpate for sacral oedema |
Auscultate lung bases for crepitations |
Pulmonary Oedema |
Examination of Feet:
Popliteal Pulses on both legs |
Dorsalis Pedis Pulses in both feet |
Posterior Tibial Pulses in both feet |
Inspect for Peripheral Oedema: |
Press for 5sec behind the medial malleolus and feel for any indentation afterwards |
Conclusion:
Thank patient and explain that the examination is finished
Sanitise Hands |
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