CLINCAL EXAMINATION BASICS

BASICS OF CLINICAL EXAMINATION


Principles of history taking & physical examination


GEnERAL PRinCIPLES



Surface anatomy of the neck

(A) Feel the following structures in the middle line as YOU
pass your finger from the chin to the sternum:
1. The chin.
2. The body of hyoid bone at C3..•
3. The notch of thyroid cartilage at C4.
4. The arch of cricoid cartilage at C 6.
5. The rings of trachea from C 6 downward.
6. The suprasternal notch.
***The lsthmus Of the thyroid gland lies over tracheal rings 2,3,4.***
(B) The lower border of the cricoid cartilage
is a very
important Landmark, it marks the following features:
1. The level of the 6th cervical vertebra.
2. The level at which you can compress the common carotid artery against the transverse process of C 6.
3. The level at which larynx ends and trachea begins.
4. The level at which pharynx ends and esophagus begins.
(C) SURFACE MARKINGS
(1) The sternomastoid muscle:
Turn your face to the left side and notice that the right sternomastoid muscle becomes prominent.
(2) The jugular veins:
The external jugular vein can be seen on the surface of the sternomastoid, it lies in the superficial fascia and descends almost vertically from the angle of the mandible towards the middle of the clavicle. The internal jugular vein lies below the sternomastoid muscle.
(3) The Carotid arteries:
a- The common carotid artery enters the neck by passing behind the sternoclavicular joint, at the level of the upper border of the thyroid cartilage.
You can feel the pulsation of the common carotid artery by pressing it backwards against the carotid tubercle. (Which is the anterior tubercle of the transverse process of C 6) medial to the sternomastoid muscle.
b- The common carotid artery is represented on the surface by a line which joins two points:
1- The sternoclavicular joint,
2- A point mid way between the tip of the mastoid process and the angle of the mandible.



SURFACE ANATOMY OF THE UPPER LIMB
(1)
Shoulder region:

* The acromion process lies immediately above the smooth bulge the deltoid muscle.

(2) Elbow region:
* Three bony landmarks which form a triangle:
- Olecranon process of the ulna.
- Medial and lateral epicondyles of the humerus.
- Brachial artery felt medial to the tendon of biceps.

(3) At the wrist:
- Feel the scaphoid bone in the anatomical snuff box.
- Feel pulsations of radial artery, lateral to tendon of flexor carpiradials.
- Feel pulsations of ulnar artery lateral to tendon of flexor carpiulnaris.

(4) Muscles:

~ Pectoralis major forms the anterior fold of axilla while teres major and Latissimus dorsi form the posterior fold.
~ Deltoid forms the smooth contour of the shoulder.

(5) Arteries: (Sites of palpation)
~ Subclavian artery ~ against 1st rib.
~ Brachial artery ~ against the humerus.
~ Radial and ulnar artery ~ at wrist (as above).

(6) Nerves:
~ We can feel the ulnar nerve near by the medial epicondyle.



SURFACE ANATOMY OF THE LOWER LIMB

(1) The femoral artery:
~ You can feel its pulsations at the mid inguinal point.
~ Surface markings, flex your hip and externally rotate it, then draw a line joining the mid inguinal point with adductor tubercle (run your fingers down the medial side of your thigh till they are stopped by the adductor tubercle). The upper 2/3 of this line is a mark of femoral artery.
(2) Popliteal artery:
~ Patient in the prone position, flex knee and use firm pressure against the popliteal surface of his femur (see later).

(3) The Dorsalis pedis artery:
~ Felt on the dorsum of the foot lateral to the tendon of the extensor hallucis longus, against navicular bone. In 10% of people it can not be felt.
(4) Post tibial artery:
~ Felt below and behind the medial malleolus. It is not felt in 5% of population.

(5) Nerves:
~ Only one nerve can be felt in lower limb (LL.) (lateral popliteal nerve), it can be rolled against the neck of the fibula.

يتبع

History taking


A ) Personal history
:
1) Name:
~ Insist upon recording the complete name including the family name (filing system).
~ Fatal errors may occur when two patients with the same name have been under treatment in the hospital simultaneously.
~ This gives sense of familiarity, sex identification.
2) Sex:
~ Diseases which are common in females as:
1. Systemic lupus erythromatosis.
2. Thyrotoxicosis - Myxoedema.
3. Gall bladder diseases e.g. gall stones.
4. Bronchial adenoma.
5. Primary biliary cirrhosis.
6. Myasthenia - chorea - meningioma.
~ Diseases which are common in males:
1. Coronary heart disease.
2. Bronchogenic carcinoma.
3. Hemophilia, Duchenne. (X - Linked)
4. Peptic ulcer, Cancer stomach.
3) Age:
~ We ask about the age because some diseases are common in children and young adults e.g.:
1. Acute rheumatic fever and rheumatic heart diseases.
2. T.B.
3. Viral hepatitis.
4. Hemolytic anemia - Acute leukemia.
5. Poliomyelitis - Duchenne myopathy - Friedrich's ataxia -
6. Tumors occuring in children include :
Wilm's tumor of the kidney , Acute leukemia , Retinoblastom , Medulloblastoma.
~ Diseases which are common in old age include :
1- Carcinoma.
2- Atherosclerosis and coronary artery disease
3- Cor - pulmonale
4- Chronic lymphatic leukemia.
5- Multiple myloma
4) Occupation:
Certain occupations may expose the patient to certain diseases:
1- Lead workers ~ Lead poisoning (Anaemia - Nephropathy - Neuropathy).
2- Glass workers : Silicosis - Interstitial pulmonary fibrosis
3- Deep X-ray irradiation : Bone marrow depression - sterility.
4- Asbestosis : interstitial pulmonary fibrosis - mesothelioma - bronchogenic carcinoma.
5- Manganese : Parkinsonism.
6- Aniline dyes : Cancer urinary bladder.
7- Sewers : Infections e.g. : leptospirosis.
8- Farmers : Bilharziasis.
5) Residence & Address:
This may reflect socioeconomic condition and may occasionally point to a certain disease e.g. :
~ eastern Egypt & northern sudan : Filariasis!?
~ Country : Bilharziasis, exposure to animals (Brucellosis) or insecticides.
~ Towns : Hypertension, Anxiety and IHD.
6) Marital State:
~ Duration of marriage.
~ Number of children.
~ The age of the youngest child.
~ social class :
a) High social class liable to Hypertension - I.H.D-
& irritable bowel disease
b) Low social class liable to malnutrition, infections & parasites.[/color]
7) Habits:
Special habit is a habit that makes the patient more susceptible than other to a certain disease :
++ Smoking ++
Ask about : Number of cigarettes / day, duration & type of smoking (pipe, cigarette).
Smoking predispose to:
1. Chest:
(a) Chronic bronchitis, emphysema.
(b) Bronchial carcinoma
(c) cancer lips & tongue due to pipe smoking
(d) post-operative pneumonia
The risk is directly proportional to the amount smoked and to the tar content of cigarettes. Staining on the fingers or teeth should raise strong suspicion that the patient is or until recently was a heavy smoker.
Smoking habits which increases the risk of bronchial carcinoma are:
a) Starting to smoke at early age, b) Inhaling smoke.
c) Increased number of puffs/cigarette.
d) Keeping the cigarette in the mouth between puffs.
e) Smoking down to the button-end. .
2. CVS : Arrhythmia - I.H.D - perjphera] vascular diseases.
3. GIT : Peptic ulcer - cancer oesophagus - cancer stomach.
4. Other complications : cancer bladder, intrauterine growth retardation,
tobacco amblyopia, cerebrovascular diseases.

يتبع

السلام عليكم ورحمة الله تعالى وبركاته

اليكم روابط مواقع مهمة ومفيدة وشاملة فى اساسيات الفحص السريرى

CLINICAL EXAMINATION

•.♥.• أفضل مجموعة فيديوهات شرح
Bates' Guide to Physical Examination
http://www.mansmed.net/forums/showthread.php?t=10849

' Bate's visual guide to physical examination
http://library.chattanoogastate.edu/bates/

Physical examination video series
http://www.learnerstv.com/Free-Medical-Video-lectures-ltv032-Page1.htm

كتب دكتور اسامة محمود
http://www.mediafire.com/?6ug2zn6x05110we

A Visual Guide to Physical Examination | Direct and Fast Video Links
كمال سيد الدراوى

Assessment of the Elderly.FLV
دكتور كمال سيد الدراوى

Examination of the Spleen
دكتور كمال سيد الدراوى

How to Read a Chest X-Ray




The Chest X-ray is one of the most commonly seen plain films you will encounter anywhere, and there are many ways to read a chest x-ray ,But a systemic approache is usually the best.


When you read CXR you have to comment on the following


The views of CXR
PA ( the most common one) , AP or lateral view
How to diffenetiate between PA and AP view ?
Simply by the direction of the ribs and shape of the clavicles


Inspiratory or Expiratory film
chest X-rays are typically done with full inspiration
How do you know ?
by the shape of ribs and diaphragm (curved or horizontal ribs/ diaphragm)
Can you see 6 anterior ribs or 10 posterior ?



Qualitiy of the film
if there is adequate exposure and penetration
or simply by looking at intervertebral disc if it is black usually this is a good quality film


Features that are usually examined
Bones
systematically look at shoulders, clavicles, sternum, then ribs
Freacture ?
Abnormalities?

Diaphragm
Look at the shape of the diaphragm and where it meets the heart,CaridoPhrenic Angle , and costophrenic angle

Obliterated?
obtused ?

Trachea
mid-line or shifted

mediastinal shadow
present or absent?

lungs parenchyma
for consolidation, granulomas, lung masses etc

روابط مهمة
Basic Interpretation of Chest Radiography
By Dr. ChiaKokKing
دكتور كمال سيد الدراوى

Breath Sound Assessment

Overview
Although many newer imaging techniques for the evaluation of lung pathology have been developed, auscultation of the chest remains an invaluable clinical tool and is still probably the most common method of evaluating the lung. Evaluation of lung sounds is a routine part of a clinical examination.

Breath sounds can be classified into 2 broad categories: normal breath sounds and adventitious (or abnormal) sounds. Adventitious breath sounds include wheezes, coarse crackles, fine crackles, and rhonchi.[1]

See the video of breath sound assessment, below.
http://emedicine.medscape.com/article/1894146-overview
Technique
Approach Considerations
A significant amount of information about the upper and lower airways and lung parenchyma can be obtained by listening to the chest. Relevant lung anatomy is depicted in the images below.


Anterior view of lungs and trachea.

Posterior view of lungs and trachea.

Assessment of Breath Sounds
If possible, auscultation of the chest should be done with the patient in the seated position. The diaphragm of the stethoscope should be used. The examiner should warm the stethoscope between his or her palms before placing it on the patient's chest. The stethoscope should be placed against the patient’s bare skin; the examiner should not try to listen through the patient's clothes.

The examination should include listening to the anterior chest, the midaxillary region, and the posterior chest. The posterior chest should be examined from the apex to the base of the chest. The breath sounds should be assessed during both quiet and deep breathing. A full breath should be auscultated in each location. The examiner should listen for the pitch, intensity, duration, and distribution of breath sounds, as well as note any abnormal or adventitious sounds.[2, 3]

Types of Breath Sounds
Breath sounds can be divided into 2 categories:
normal and
abnormal (adventitious).

Normal breath sounds
Normal breath sounds can be further divided into 2 subcategories: vesicular and tracheal. Vesicular breath sounds are the sounds heard during auscultation of the chest of a healthy person (listen to the audio recording below). The inspiratory component predominates and is generated by turbulent airflow within the lobar and segmental bronchi, whereas the expiratory component is due to flow within the larger airways.

[color=blue]Vesicular breath sounds (MP3) Audio courtesy of MEDiscuss.
اضغط الرابط
دكتور كمال سيد الدراوى
Tracheal sounds are the sounds heard over the sternum. They are louder and higher pitched than vesicular sounds are. With tracheal sounds, the expiratory phase is as long as or longer than the inspiratory phase.[2, 3, 4]

Abnormal (adventitious) breath sounds
Wheeze
اضغط الرابط دكتور كمال سيد الدراوى

A wheeze is defined as a continuous musical sound lasting longer than 250 ms (listen to the audio recording below). It is thought to be due to oscillation of opposing airway walls that are narrowed almost to the point of contact. A wheeze may be either expiratory or inspiratory and may contain either a single note or multiple notes. Wheezing is common, estimated to occur in 25% of the population at some point. It is frequently more audible at the trachea than in the chest.[5]

Clinically, wheezing indicates airflow obstruction, though its absence does not exclude obstruction. Such obstruction may occur at any point along the airway. Conditions associated with wheezing include infection (croup, whooping cough, bronchiolitis), laryngeal or tracheal tumors, tracheal stenosis, tracheomalacia, foreign body aspiration, other causes of large airway compression or stenosis, vocal cord dysfunction, asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, bronchiectasis, hypersensitivity pneumonitis, and pulmonary edema.
A wheeze may be detected during forced expiration in normal subjects. Although wheezing is associated with airflow obstruction, the degree of obstruction cannot be reliably predicted by the presence or absence of wheezing. Generally, a polyphonic wheeze (ie, a wheeze with multiple notes) is characteristic of large airway obstruction, whereas a monophonic wheeze is more typical of small airway obstruction.[4, 5]

Squawk

A squawk is defined as a very short wheeze. It is thought to occur when a closed airway suddenly opens during inspiration and the airway walls briefly remain in light contact. Squawks are most common in fibrotic disorders, particularly hypersensitivity pneumonitis.[5]

Crackles
اضغط الرابط دكتور كمال سيد الدراوى
Crackles are defined as a short, explosive, nonmusical sound (listen to the audio recording below). The can be divided into 2 types: fine and coarse. Compared with coarse crackles, fine crackles have a higher frequency and a shorter duration. Fine crackles are caused by the sudden opening of a closed airway; coarse crackles are thought to be related to secretions.
Crackles may occur on either inspiration or expiration but are more common during inspiration. Inspiratory crackles may be classified as early inspiratory, midinspiratory, or late inspiratory. Crackles are more frequently heard in the basilar regions of the lungs because the distribution of airway closure is gravity dependent.
The number of crackles has been shown to correlate with disease severity. Crackles may be heard in cardiac disease, fibrotic lung disease, obstructive lung disease, and pulmonary infections. They may also be heard in healthy older individuals.[4, 6]
General characteristics of these crackles have been described for many different disorders (although there may be variations among individual patients). In idiopathic pulmonary fibrosis, crackles have been described as fine, short in duration, higher pitched, and occurring in late inspiration. A basilar predominance exists in early disease.

Asbestosis is associated with fine crackles. The presence of crackles has been shown to be associated with honeycombing on imaging and with the duration of dust exposure. In bronchiectasis, crackles have been described as high frequency and coarse. They occur in early inspiration or midinspiration and are thought to be secondary to bronchial wall collapse during expiration and sudden opening in inspiration.

In COPD, crackles are most commonly due to airway secretions and typically disappear after coughing; they may also be due to the opening and closing of narrowed bronchi with weakened airway walls. Crackles in COPD are characterized as coarse, early, and low pitched and tend to be infrequent.

The crackles associated with pulmonary edema are attributed to the opening of airways narrowed by peribronchial edema. They are described as coarse, late occurring, and high pitched. They may be inspiratory or expiratory.

In pneumonia, 2 types of crackles have been described. Early pneumonia is associated with coarse, midinspiratory crackles. Crackles during the recovery phase are described as shorter and occurring at the end of expiration.

Crackles are relatively rare with sarcoidosis (because of the upper lobe predominance of the disease); when they do occur, they are described as fine and either late inspiratory or midinspiratory[6] .

Rhonchi

Rhonchi are defined as low-pitched, continuous sounds that have a tonal, sonorous quality. They are caused by the rupture of fluid films and airway wall vibrations and are associated with disorders that cause increased airway secretion or reduced clearance of secretions. Rhonchi tend to clear with coughing.[2, 4]

Stridor

Stridor is defined as a high-pitched continuous sound heard over the trachea. It is due to turbulent flow generated in the upper airway during extrathoracic airway obstruction, and it tends to occur when the upper airway is narrowed to 5 mm or less. Stridor is louder than wheezing, and it is longer in inspiration than in expiration. It may be caused by any condition that leads to narrowing of the extrathoracic airway.[4]

Other abnormal sounds

Pulmonary parenchymal consolidation may cause several changes in the quality of breath sounds.
Bronchial breath sounds are breath sounds that are overly well transmitted to the chest wall as a consequence of increased sound transmission through the consolidated lung parenchyma (listen to the audio recordings below). These sounds are described as similar to tracheal sounds and are loud, high pitched, tubular, and whistling. Expiration is as loud as, or louder than, than inspiration.

Bronchial breath sounds (MP3) Audio courtesy of MEDiscuss.
http://www.4shared.com/mp3/ctEuy4AO/bronchial_breathing.html?

Bronchovesicular breath sounds (MP3) Audio courtesy of MEDiscuss.
http://www.4shared.com/mp3/iW605bJa/bronchovesicular_breathing.html?

Consolidation also leads to changes in voice-generated sounds. Normally, the spoken voice has a muffled, indistinct quality when heard during auscultation of the chest. With a consolidated lung, the voice may take on a high-pitched, bleating quality (egophony) or may exhibit increased pitch or transmission of words (bronchophony or pectoriloquy). The so-called E-to-A sign has also been described, in which a spoken “E” sounds like “A” on auscultation of the abnormal area.[4]

Several conditions are associated with a decrease in or absence of normal breath sounds. Diffusely decreased breath sounds may be noted in conditions that alter the transmission of sound through the chest wall (eg, obesity), as well as in obstructive lung disease. A focal decrease or absence in breath sounds may be due to pleural effusion, pneumothorax, or atelectasis.[4]

ملفات طبيب (1)

history taking



بسم الله الرحمن الرحيم



السلام عليكم ورحمة الله وبركاته



ملفات طبيب , سلسلة تعليمية من داخل المستشفيات , تحكي للطلاب طريقة اخذ التاريخ المرضي للمريض على اختلاف مراحله العمرية , بعضها من ملفاتي واخر من زملائي , اضعها لكم , وهدفي الأول هو أن استفيد من نقدكم وتوجيهاتكم , وهدفي الاخر أن تستفيدوا من ما كتبت ,


واليكم هذا المثال
----------------------------------

HODA ABDULLA

four years old ,saudi girl

source of history : mother who is reliable .



CHEIF COMPLIANT :
Cough and difficulty of breathing for 2 days .

fever for 1 day



patient is known case of asthma for the past 3 years ,diagnosed at (RC HOSPITAL ) when she was 1 year old .



HISTORY OF PRESENT COPLAIN :
pateint known case of bronchial asthma and not in regular medication exccept 4ml ventoline syrup PRN .

Tow days back , she started to have difficulty of breathing ,sever in nature , continous . there is no stridor or wheezing .Increasing in time with time mainly at night . It was aggravated by exercise ,not relieved by rest or ventolin . It si associated with dry cough , whitch is intirmittent , interfered with speaking , sleeping and feeding .It is aggravated by exposure to perfumes and relived spontaneously .



One day befor admission , fever started at home gradually and documented at home {38 C} .Associated with sweating and chillis but no convolsions .NO history of vomiting or diarrhea .



Regarding similar attaks , The last one was milder and relived by ventolin syrup at home . Usually the attacks are triggerd by exercise ,perfumes , dust, URTI ,exposure to cold or crying . The attacks are usually relived by rest and ventolin syrup .usually there is one or two attacks per month in summer , and 3 to 4 attacks per month in winter . Each attacks lasts 4 to 6 days .



There is no history of nasal obstruction , rhinorrhea, eye redness, eczema or skin rashes .



The pateint was admitted after no improvement was detected in the pateint status after giving her nobulized ventolin and oxygen in ER .



PAST MEDICAL AND SURGICAL HISTORY :


BRONCHIAL ASTHMA diagnosed 3 years ago .

No Hx OF CHRONIC DISEASES

No Hx of surgical opearations.

No Hx of blood transfusion .



PREGNANCEY AND ANTENATAL Hx :


Full term

Birth weight 3.5 kg .

No maternal illness during pregnancy

Discharged 1 day after delivery



NUTRITIONAL Hx :


On family diet ,normal appetite .



DEVELOPMENTAL Hx :


normal development

she can run , jump and climp stairs 'dress by herself , draw a square and talk normally

normal vision and hearing .



ALLERGY Hx :


No know hx of allergy to food or medications .



IMMUNIZATION Hx :


she took all vaccines up to date .



DRUGS Hx :


on 4 ml ventolin syrup PRN

NO other regular medications



FAMILLY Hx :


father, 32 y high school education.

mother ,27 y high school education

childern (boy 7 years ,and two girls 4 y and 2 years .)

parants both well and healthy .

no consengcinity between her parants .

no family history of similar conditions .

no hx of abortion



SOCIAL Hx :


Living with her parants on riyadh .

living in a villa , good condition

no smokes ,gardness or animals in home .





SYSTEMIC REVIEW:


RESPIRATORY SYSTEM :


S.O.B - COUGH

NO stridor or wheezing

No chest pain or rhinorrhea



CVS :


NO CYANOSIS OR PALPATIONS



GIT :
no vomiting ,dirrhra ,abdominal pain or jaundice .



US :
no dysurea , haematurea , incontinence or noctouria

normal frequancy .



CNS :
no headache , weakness, numbness , funny turns or seizure



MUSCULOSKELETAL :
no joint pain ,joint swelling or skin rash .



HAEMATOLOGICAL :
no paller , jaundice , bone pain , bruises or bleeding from nose >
--------------------------------

ملحوظه :

الاسماء مستعارة حفاظا على سرية المريض ,
--------------------------------

DOCTORS & STUDENTS COMMENTS

Doctor:

Thank you very much for this funny and seientific idea

I will talk in ideal method which we learn it , not method we used it in practical duties


1st : In personal data : what is about address and date of admession


2nd : chief Complaint : 100% esp. it writen by patient relative WORDs but you say "patient is known case of asthma for the past 3 years ,diagnosed at (RC HOSPITAL ) when she was 1 year old" . I think it must be put in history of present illness ! only idea not more !!!!


3th : you write "history of present illness" in good methed which include all ass. Factors at all levels....( I am happy from this parts:64)


4th : In " Review of system" some of Medical school recomment starting from above to downward ( start from CNS) while othes like starting from system which has chief complaint ( Respiratory System here) >>>> it only differnce in school but has no effect on final report


5th: Use masked names of patient is a good method which keep personal and social privacy. Also, it reflect a good communcation with patient and give good impression about doctor and his/her ethics


Finally: it is my opionion Reflect my view about history taking ONLY

Best Wishes Doctor in your duties

تعليق طبيب اخر

فكره رائعه جداً

تشكر عليها

لكن لما لم تضع لنا نتائج الفحص السريري ؟

أو انك تريد ان يكون المجال مفتوحاً للنقاش .. ثم يضاف الفحص السريري بعد ذلك ؟


.

اساسيات الكشف والتشخيص
http://www.themdsite.com/


Cardiovascular system PHYSICAL EXAM




Adult Cardiovascular Examination/ OSCE guide




Introduction

Introduce yourself
Explain what you would like to examine
Gain consent
Place patient at 45° with chest exposed
Ask if patient has any pain anywhere before you begin!

General Inspection


Bedside for treatments or adjuncts – GTN spray, O2, Tablets, Wheelchair, Warfarin
Comfortable at rest?
SOB
Malar Flush
Chest for scars & visible pulsations
Legs for harvest site scars and peripheral oedema
..

Hands

Temperature - poor peripheral vasculature
Capillary refill – should be <2 seconds
Colour – cyanosis
Clubbing
Splinter haemorrhages, Jane-way lesions, Oslers Nodes – infective endocarditis
Palmar Erythema – hyperthyroidism, pregnancy, polycythaemia
Nicotine Staining – smoker

Pulses

Radial Pulse – rate & rhythm
Radial-Radial Delay – aortic coarctation
Collapsing Pulse – aortic regurgitation
BP – narrow pulse pressure = Aortic Stenosis | wide pulse pressure = Aortic Regurgitation
Carotid – character & volume
JVP – measure and also possibly carry out hepatojugular reflex

Face

Eyes – conjunctival pallor, jaundice, corneal arcus, xanthelasma
Mouth – central cyanosis, angular stomatitis
Dental hygiene – infective endocarditis

Close Inspection Of Chest

Scars - lateral thoracotomy (mitral valve), midline sternotomy (CABG), clavicular (pacemaker)
Apex beat – visible in aortic regurgitation and thyrotoxicosis
Chest wall deformities – pectus excavatum, pectus carniatum

Palpation

Apex beat – 5th intercostal space, mid clavicular
Heaves- left sternal edge – seen in left & right ventricular hypertrophy
Thrills – Palpatable murmurs over aortic valve & apex

Auscultation

Listen over 4 valves - ensure palpation of carotid pulse to determine first heart sound
Roll onto left side & listen in mitral area – mitral stenosis
Lean forward & listen over aortic area- aortic regurgitation
Carotids - radiation of aortic stenosis murmurs & bruits
Lung bases – pulmonary oedema
Sacral Oedema & Pedal Oedema

To complete the examination

Thank Patient
Wash hands
Summarise Findings


Say you would

Assess peripheral pulses
Carry out an ECG
Dipstick urine
Bedside Blood Glucose
Fundoscopy
..
..

Macleods clinical Examination-examining ...
http://www.4shared.com/file/tOhF3NJN/Macleods_clinical_Examination-.html?