Physical Exam






















Introduction

The cardiovascular system is one of the few systems which lends itself to physiologic bedside diagnosis.Through undue reliance of technology and dilution of physical exam skills, examination of the cardiac system is a lost and eroding art . A thorough awareness of the physiologic significance of cardiac physical signs will allow the skilled observer to piece together cardiac diagnoses at the bedside, assess the severity of hemodynamic lesions and ascertain prognostic information from such diverse findings as pulse contour, JVP waveform and cardiac apical impulse. The purpose of this webpage is to provide a concise grounding in cardiac physical exam skills as well as links to other sites which will aide the keen observer in honing their bedside cardiovascular examination.
 
As you approach the cardiac patient, examine from the periphery to the centre, from the extremity for pulse rate, rhythm and regularity to palpation for of brachio-radial delay and forearm compression to detect water-hammer pulse. Examine the JVP for height and waveform and the carotids for volume and upstroke. Palpate the precordium for palpable heart sounds, abnormal impulses, lifts,thrills, and apical dynamic qualities. Put the pieces of the puzzle together as you go. By the time you put the stethoscope on the chest, you should know what you should hear. If you do not hear what you expect, explain why and re-analyze your data to synthesize the diagnosis. Do not be satisfied with mere description. Ask yourself:" What is the cause of this murmur? Is it hemodynamically significant? How severe is the lesion? Is LV function normal? What is the ejection fraction? the valve area? the predominant lesion? Do not leave the bedside until you are committed to your diagnosis.
 
For a more thorough review of the cardiac exam I recommend Bedside Cardiology, Fifth Edition  by Jules Constant. ©LIPPINCOTT WILLIAMS AND WILKINS

 

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  Version 2.0, April 2007
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