WIPER and General examination
In an examination the mnemonic WIPER may serve as a reminder to wash your hands, introduce yourself, gain permission, expose the patient and reposition them as appropriate for the examination about to be performed. Simultaenously you should carry out a general examination noting the patients appearance, condition, and any clues from the environment. This forms the beginning of your mental account of the patient and can be remembered as ACC. See General Examination and Observations for more detail. The standard format that follows is always inspection, palpation, percussion, auscultation, and contemplation (Osler, Canadian turn of 19C physician, father of modern medicine). Additionally it is helpful to carry out the examination routine in a set sequence for example general, hands, neck, face, then specific, in this case, the chest wall. Finish by carrying out, or listing, relevent further clinical examinations and investigations, and presenting your findings. N.B. It’s a good idea to aim to be able to define, explain, and suggest a differential for any finding that you report.
Cardiovascular examination
General inspection
Is the patient fat? Obesity is a risk factor for heart disease Is the patient thin? Weight loss is a symptom of heart failure Is the patient SOB, do they have ankle oedema, a raised JVP? Could be heart failure Is there a midline stenotomy scar? Is there evidence of harvesting of the long saphenous vein? Is there a relevent spot diagnosis? E.g Malar flush, thyrotoxicosis, etc Are they attached to a cardiac monitor? If so what does it show?
Hands
Is there tar staining, clubbing (test), cyanosis (could be hypoxaemia or peripheral vasoconstriction), abnormalities of peripheral perfusion (hands warm and pink, cap refill < 3s normal) stigmata of infective endocarditis (splinter haemorrhages, osler’s nodes, janeway lesions)
Radial pulse, rate, rhythm, radioradial delay, collapsing pulse if no pain in shoulder. BP (left and right) ALWAYS ask for it/say you would do it if you don’t do it.
Neck
Carotid pulse, character (normal, collapsing, bounding, slow-rising, ?pulsus paradoxus) ?bisferans, alternans
JVP (raised, normal, cannon a wave, large v wave etc) (abdominojugular reflux sign)
Face
Eyes, signs of hyperlipemia such as xanthelasma, corneal arcus. Mouth, central cyanosis, dentition.
Chest wall, anterior and posterior
Inspection
Put your hands behind your head, scars (look at legs for harvesting of long saphenous vein too), abnormal pulsations
Palpation
Apex beat, position, character, heaves and thrills
Percussion
No percussion in a CVS exam
Auscultation
Listen first with bell, feel carotid simultaenously. Roll pt. to left (mitral stenosis) Mitral, tricuspid, pulmonary, aortic regions, HS I + II, added sounds? Mumour? Where loudest? Systolic/diastolic? Radiating? Sit forward expire hold (aortic regurg) carotids expire hold (carotid bruit).
Auscultate lung bases, check for sacral oedema and ankle oedema
Completion
Either do these things and/or say ”To complete my examination I would….``
Further examinations
Peripheral pulses (peripheral vascuar examination), varicose veins (legs), liver (abdomen), fundoscopy (hypertensive retinopathy, diabetic retinopathy ?papillary oedema etc)
Further investigations
Simple tests: urine dipstix, glucose, microscopic haematuria (*if* you’re thinking IE)
Blood tests: Fbc, U&E’s, inflammatory markers, cardiac enzymes
Imaging: ECG, CXR,
Special test: ETT, echocardiogram, angiography, thallium scan, 24 hour tape for arrythmias.