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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