1. Environment, general appearance
2. Nails, hands, arms
3. Face, eyes, mouth
4. Neck, JVP
5. Chest: insp, palp, ausc
6. Back
7. Abdomen
8. Legs, feet

Environment

• ECG leads, machine.
• Support hosiery.

General appearance

• Colors:
  • Cyanotic.
  • Pallid (anemia).
  • Jaundiced (anemia, EPO insufficiencies).
  • Hyperpigmented (hemochromatosis cardiomyopathy, Addisonian hypotension).
  • See Skin Colors Reference.
• Weight loss.
• Glaring breathing problems.
• Syndromes: Down's, Marfan's, Turner's.
• Leg hanging over edge of bed: peripheral vascular dz.

Nails

• Ask pt. to sit at 45°.
• Clubbing, stage 1-5 (cyanotic heart dz, IE).
• Splinter hemorrhages (IE).
• See Nails Reference.

Hands

• Peripheral cyanosis.
• Arachnodactyly (Marfan's).
• Pallor of palmar creases (anemia 2° to blood loss, malabsorption).
• Osler nodes [0.5-1 cm red-brown painful subcutaneous papules on fingertips, palmar eminences] (IE).
• Janeway lesions [rare, painless flat erythematous macules on thenar and hypothenar eminences] (IE).
• Wrist: tendon xanthoma [yellow deposit over extensors] (type II hyperlipidemia).
• Heat (thyrotoxicosis).
• Tremor (thyrotoxicosis).
• Pulse: rate, rhythm, character, radiofemoral delay, radioradial inequality. See Pulse Reference. Say "character, volume better assessed at the carotid".
• If suspect AR, assess 'water hammer pulse':
  • Dr's 4 fingers horizontal over pt's palmar wrist, as flex and extend pt's elbow.

Arms

• Take blood pressure.
• IV drug injection scars (IE).
• Optionally raise arm to see if less circulation.

Face

• Facies:
  • Apprehension, pain (angina, MI, PE, etc).
  • Cushing's (HTN).
  • Acromegaly (CHF, HTN).
  • Paget's (high output failure).
• Malar flush [thin face, purple cheeks] (mitral stenosis).
• Earlobes (cyanosis).

Eyes

• Xanthelasma [yellow plaque periobital deposits] (hypercholestolemia, DM).
• Lid edema (myxedema, SVC syndrome, nephrotic syndrome, etc).
• Exophthalmos, lid retraction (thyrotoxicosis).
• Corneal arcus (severe hypercholesterolemia).
• Blue sclera (Marfan's Ehlers-Danlos's [AR, ASD, MVP]).
• Subluxated lenses (superior: Marfan's, inferior: homocystenuria).
• Argyll-Robertson pupil (syphilis).
• Ophthalmoscope fundi: 
  • Roth's spots [small red hemorrhage with pale center, due to vasculitis] (endocarditis).
  • Hypertensive changes.
  • See Fundus Examination.

Mouth

• Lips: central cyanosis.
• Tongue underside: central cyanosis.
• Tongue enlargement (amyloidosis).
• Torch: high arch palate (Marfan's).
• Breathing: dyspnea + wheezing (asthma, COPD, asthma, LV failure).
• Breathing: Chyne-Stokes breathing (stroke, CHF, sedation, uremia).

Neck

• Tell pt. to remove shirt now or during chest exam. Cover woman's breasts with loose material.
• Using accessory muscles of respiration (pulmonary edema, asthma, fulminant pneumonia, COPD).
• Carotid: inspect for carotid pulsations.
• Carotid: compress one carotid at a time [fingers behind neck, thumb at or below cricoid cartilage level. Optionally use just L thumb to assess R carotid--some teachers disapprove but carotid pulse outweighs thumb]. Assess:
  • Amplitude.
  • Contour of pulse.
  • Variations in amplitude.
• Carotid: auscultate bruit:
  • Use bell of stethoscope.
  • Tell pt. to hold their breath while Dr listens.

JVP

• JVP [use R one]: inspect height, character.
• JVP: Kussmaul's sign [change on inspiration].
• See JVP Reference for more details.

Chest: inspection

• Scars, including mitral valvotomy laterally on L breast.
• Deformities, dressings, stitches, etc.
• Visible pulsations.
• Apex beat.

Chest: palpation

• Ask pt. if any part is tender, examine that last.
• Pacemaker boxes.
• Palpate apex beat for presence, deviation, character. See Apex Beat Reference.
• Parasternal impulse:
  • Heel of Dr's hand to L of sternum.
  • If RV, LA dilated, heel will lift on systole.
• Thrills and heaves:
  • Dr's hand horizontal under R pectoral, then vertical up medial side R pectoral, then horizontal across center of ribcage, below sternal notch.
  • Diastolic thrill: doesn't coincide with apex beat.
  • Systolic thrill: coincides with apex beat.
• Pulmonary component of S2.

Chest: auscultation

• Heart sounds, 1st, 2nd split.
• Murmurs.
• Time according to carotid pulse (atrial fibrillation: not all apex beats become pulses).
• Dynamic auscultation.
• If systolic murmur, do Valsava maneuver (hypertrophic cardiomyopathy).
• If mitral stenosis, hear thrill by rolling pt onto pt's  L side [brings apex closer to chest wall].
• See Heart Sound Reference.

Back

• Pt. leans forward.
• Inspect for deformities (ankylosing spondylitis, with AR).
• Percuss back (exclude an RVF pleural effusion).
• Palpate sacral edema.

Abdomen

• Liver: find, examine edge.
  • See Liver Palpation.
• Liver: pulsatile liver (tricuspid regurgitation).
• Splenomegaly (endocarditis).
• AAA.

Legs

• Inspect: edema.
• Inspect: peripheral vascular dz.
  • May also see marks of pt squeezing thigh to increase perfusion.
• Femoral pulse.
• Varicose veins. See Varicose Veins Examination.
• Ulcers. See Ulcers Examination.

Feet

• Rest of peripheral pulses.
• Achilles tendon xanthomata.
• Same signs as Hands and Fingernails.