Author: Claire

Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta. Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.

Hope Through The Storm: A Gentle Reminder From The Universe

Whenever we experience emotional turbulence, the universe does its best to gently reminds us of one timeless truth:

There is always hope.

No matter how heavy the burdens you may be carrying, no matter how lost or overwhelmed you may feel, hope should always be your guiding light.

Feel It Then Heal It

Yes it’s okay to cry. It’s okay to feel anger, grief, or confusion. You’re human, and your feelings are valid.

But after those feelings have been acknowledged and honoured, take a conscious step toward soothing yourself back into alignment. Find that small flame of hope deep within and let it grow.

A Reason for Everything

Even the most painful moments may be divinely orchestrated stepping stones. What feels unbearable today may turn out to be exactly what your soul needed for deeper growth, healing, or redirection.

Let go of resistance and trust the bigger picture.

You Are Never Alone

Always remember: You are loved. You are valued. You matter. Even when you feel alone, you are not. Look around. Seek those who truly have your back, who care deeply, and who show up for you when it counts. Let their light guide you through your darkest nights.

Let Hope Lead the Way

When you choose to hope even in the face of fear or uncertainty, you open the door to miracles. You reconnect with your soul and align with the greater flow of divine love and wisdom.

So today, take a breath. Place your hand over your heart. And remind yourself: “This too shall pass. Something beautiful is on its way.”

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5 Simple Steps To Creating The Life Of Your Dreams offers a break-through holistic approach that aims to promote overall wellbeing on a day-to-day basis, guiding you towards creating and maintaining a positive approach to life through 5 simple steps.

When The Bridge Burns: Trusting Divine Timing

There are times in life when we encounter fiery, intense, or even conflicting situations that seem to leave us shaken. These moments may involve short-term relationships, fleeting opportunities, or connections that feel significant, but are not built to last.

Sometimes bridges are meant to burn. And when they do, it is not our task to chase after the ashes or rebuild what has already served its purpose.

Whether it’s a sudden fallout, an unexpected ending, or a turning point that catches you off guard, this is a divine invitation to surrender. The Universe is gently reminding us: do not resist what is naturally falling away.

Stop Fighting What’s Fading

When you try to hold onto something that is unraveling, it only creates pain and resistance. What’s meant to fall away will do so, whether you fight it or not.

This isn’t a punishment—it’s divine redirection.

Instead of seeking resolution for every ending, learn to trust in the unseen orchestration of your life. You may not yet understand why something is leaving, but its absence is creating space for something far more aligned to enter.

Have Faith in the Bigger Picture

Remember, your story is part of a much larger, divinely woven tapestry. What feels like loss today may be making room for a new chapter of purpose, clarity, and fulfillment.

Trust that every event, even the most painful one, is a sacred step forward.

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Clarity: The First Step to Manifestation

In life we often feel weighed down by sadness, anxiety, or frustration, especially when the things we long for seem just out of reach. It’s natural to desire a better reality, but many of us forget a vital truth: the Universe responds best to clarity.

When you’re unclear about what you want, your energy is scattered. It’s like setting out on a journey without a map, hoping to somehow arrive at your destination. But when your intentions are specific and defined, you align yourself with the energy of manifestation. You create a clear channel through which the Universe can work.

Begin With Self-Reflection

The first step is to pause and reflect. Ask yourself: Do I really know what I want? Not just the vague version: wealth, love, peace, but the precise details that define it for you. For example, instead of saying, “I want to be rich” try defining what wealth looks like in your world. Is it earning a particular income? Living in a certain place? Enjoying time freedom? Clarity gives your desires structure.

Take some quiet time to think, journal, or simply sit in silence. Let your thoughts settle and let your true desires rise to the surface.

Be Specific With Your Desires

Write down what you truly want, and don’t be afraid to get specific. Include numbers, dates, environments and feelings. Act as if you’re placing a sacred order with the Universe. The more specific you are, the more aligned your energy becomes with your intended outcome.

For example:

“I want to earn €3,000 per month doing fulfilling work.”

“I want to meet a loving, spiritually aligned partner by the end of the year.”

“I want to wake up each day feeling peaceful and energized.”

Add a soft, realistic timeline, not to pressure yourself, but to strengthen your sense of direction.

Trust and Let Go

Once you’ve placed your desires out into the Universe with clarity and intention, release them. Do not obsess over how they will arrive. The “how” is not your responsibility. Your task is to trust, to keep your energy aligned, and to stay open.

Often, the path to your goal doesn’t look like what you expected. It might come through an unexpected meeting, a job offer you hadn’t considered, or an inner shift that opens a new door. Be ready. Be watchful. Your soul will always give you the nudge – follow it.

Let Your Soul Guide You

Your soul knows your path better than your mind does. Tune in. When you feel a whisper, a nudge, or an inspired idea act on it. Your intuition is the compass that will always guide you to the life you’re meant to live.

Manifestation is not magic. It is alignment. It is choosing to live with intention, trusting in divine timing, and honoring your inner wisdom.

You are never too far from what you want. Sometimes you just need to get clear.

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The Sacred Detour – An Inspirational Reflection

There comes a moment in every soul’s journey when the path forward becomes unclear. We stand at the crossroads, peering into the mist ahead, wondering which way leads us home.

We are taught to plan, to predict, to follow straight lines. But the Universe speaks a different language: a language of subtle signs, quiet pauses, and unexpected turns. And in that language, the detour is not a failure. It is a sacred redirection.

Sometimes, what feels like a delay is Divine timing rearranging itself in our favour. Sometimes, what looks like an obstacle is grace disguised as stillness. And sometimes, the way forward is not the road we had imagined, but the one that leads to something greater than we could have possibly planned.

When we let go of the need to know exactly how it will all unfold, we create space for miracles. We allow the Universe to meet us with wisdom beyond logic, with timing beyond our control. What we truly desire – peace, love, fulfillment, is not found in forcing our way forward. It is found in trusting that the way will open, when we are ready, and when the time is right.

If you are standing at a fork in the road today, know this:

You do not have to see the entire path to take the next step. You only need to trust that the light ahead will rise to meet your feet.

The destination is not lost. It is simply waiting for you to arrive with an open heart, led not by fear, but by faith.

Let the detour become your sacred turning point. Let it teach you how to surrender to the journey. And most of all, let it remind you that you are always being guided – even when the path is unknown.

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5 simple steps to creating the life of your dreams

The NUPO Diet Review: trying NUPO before going under the knife

Disclaimer: This blogpost ‘The NUPO Diet Review’ features my own personal experience trying out the NUPO diet, specifically the NUPO Very Low Calorie Diet (NUPO VLCD). This is neither a nursing-related post, nor a sponsored post.

Those of you who know me personally know that I’ve struggled with weight loss all my life. And ‘being on a diet’ has been an ongoing phase for most of my years. I’ve tried so many diets and ‘healthy eating’ ways throughout the last decades, but the problem remained.

Being a student nurse brought onto me a pile of guilt. See, I love preventive nursing and I aim to inspire my patients to be healthy in my clinical practice. But how can I do that when I can’t even lose weight myself for a healthier life?

That was when I started seriously thinking about going under the knife for bariatric surgery. At exactly 100kgs I would have had to go the private route, so I started searching for more information on the operation. I won’t go into detail on what researching the subject brought up. However, just before scheduling a private appointment with a bariatric surgeon, I came across the NUPO diet. Now THAT was something I had still not tried! Considering the thought of a non-invasive diet versus an invasive procedure, I decided to give it a go. After all, what did I have to lose apart from weight?

What is the NUPO VLCD and how does it work?

The NUPO Very Low Calorie Diet (VLCD) is an easy-to-follow diet that provides you with 800 kcal per day, which is significantly less than what the body burns during a day. This caloric deficit naturally leads to weightloss.

The NUPO diet provides you with a maximum of 50g of carbohydrates per day. Carbohydrates are the body’s primary energy source, thus, when the carb intake is low, the body is forced to find an alternative energy source. After about 2 days on the NUPO VLCD, the body’s own carb stores are depleted, and the body starts to break down its stored fat, creating ketones to use as a source of energy. Once this stage is reached, the body is said to be in ketosis – a phase characterised by a relatively low but stable blood sugar level, high ketone content in the blood, and high fat combustion.

What does the NUPO Diet meal plan consist of?

When on the NUPO VLCD you can consume 6 NUPO products per day. Typically you can have oatmeal for breakfast, a shake, soup for lunch, another shake in the afternoon, a meal in the evening, and a final shake later on. It is very important to consume all 6 portions during each day so as to ensure your nutritional needs are met.

What I love about the NUPO diet is that I find most of the products amazingly tasty! And trust me when I say, I’ve had issues with shakes in the past! Besides this, you can switch between different tastes and products, which helps you keep the excitement going.

Preparing the products for consumption cannot be easier (and having a very busy life makes the NUPO diet a sustainable option for weightloss!). Shake powder is added to 300ml of water, mixed in a shaker, and then consumed. All other products are mixed in the same way with different amounts of water, and then heated in a microwave oven for 2 minutes, or in the case of the omelet, cooked for 2 minutes per side in a pan.

As a student nurse I’ve found it really easy to carry my meals around or mix shake powder into a shaker with 300ml of water and consume wherever. Not to mention the convenience of ready-made meals which require very little preparation time!

NUPO do have other products. I have personally taken the Slim Boost Fill My Tummy fibre pills to help me curb my hunger in the initial phase, especially considering the fact that I am prone to bingeing when stressed or hungry.

and now for the results…

I decided to write this review after following the NUPO diet for just over a month so I can feature the resulting measurements here…saying I’m overjoyed is an understatement!

	*5th November 2023*	10th December 2023
*Weight*	100 kg	91 kg
*BMI*	40.1	36.5
*Neck*	41 cm	39.5 cm
*Bust*	131 cm	124.5 cm
*Bicep (R)*	42 cm	40.5 cm
*Waist*	131 cm	120 cm
*Hips*	123 cm	114 cm
*Thigh (R)*	72 cm	65.5 cm

The NUPO diet has given me the possibility to lose weight in an easy sustainable way. I couldn’t be happier! I still have a lot more excess weight to lose, so I am continuing this diet until I reach my desired weight…and I am finally confident that I will not only reach it, but be able to maintain it!

Since the weigh-in listed above, I have lost another kg in the past week…down to 90 kgs! Looking forward to touching the 80’s again most probably by next Sunday – my weigh-in day 🙂

Some may argue that 800 kcal are too little and “not healthy”. What I personally would answer is that I have weighed the pros and cons, and I believe that it is much better to follow such a diet than going for bariatric surgery which is an invasive procedure or doing nothing and ending up with cardiac disease.

Obviously, if you, reading this NUPO diet review, feel drawn to try it out, do consult your GP and get advice specific to your personal situation before starting this or any other diet.

NUPO products can be bought from all leading pharmacies across Malta and Gozo as well as from selected beauty salons. For more information you can also contact NUPO Malta on Facebook by clicking HERE.

Would you like to be a guest writer for Student Nurse Life? I’d love to hear from you! Contact me 🙂

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Antimicrobial Resistance Symposium

The Faculty of Health Sciences, University of Malta, in collaboration with the WHO Global Leaders Group on Antimicrobial Resistance, is delighted to extend an invitation to an engaging symposium focused on raising awareness about Antimicrobial Resistance. This hybrid educational event bearing the title ‘Political advocacy and closing the knowledge gaps to address antimicrobial resistance‘ seeks to shed light on the pressing issue of Antimicrobial Resistance and its profound impact on public health.

The primary goal of this symposium is to enlighten patients and the public regarding antibiotic misuse and the critical need for effective infection prevention measures. The symposium will feature insights from members of the AMR Patient Group who will share their personal experiences in dealing with resistant bacteria. Their narratives will serve to advocate for concrete actions to combat this escalating public health threat.

This Antimicrobial Resistance Symposium is going to be held on Wednesday 22nd November 2023 from 9am till 2pm CET (Malta Time). It is going to be a hybrid event – in-person at the South Auditorium, Faculty of Health Sciences, University of Malta, and virtual.

To check what the time of event is going to be for your country please click HERE.

To register for this event please click HERE.

Reference: https://www.um.edu.mt/newspoint/events/um/2023/11/amr-high-level-educational-symposium/_nocache

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Examination of the Abdomen for Nursing Students

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the abdomen.

Examination of the Abdomen Outline

general considerations
examining the hands
examining the eyes
examining the mouth
palpating the cervical lymph nodes
examining the patient’s chest
examining the abdomen

1. General Considerations

ensure your hands are warm – patient comfort
during palpation check for signs of pain in patient’s face eg. grimacing
expose the abdomen including the inguinal regions (not the genitalia) while the patient is lying flat with one pillow
if patient has a nasogastric tube notice the aspirate
if patient has a urine catheter notice the urine bag
if patient has an IV line notice what is being administered
if patient has a drain following a laparoscopy check drain for massive amount of blood, urinary output, IV fluids, NG tube aspirate, and pain relief administration

2. EXAMINING THE HANDS

FINGER CLUBBING

check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
finger clubbing causes may include gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)

KOILONYCHIA

thin concave spoon-shaped nails commonly found in anaemia due to iron deficiency

Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMicm1802104 on 30th June 2023

LEUCONYCHIA

white discolouration of the nails (possibly totally opaque) commonly found in patients with a low serum albumin a.k.a. hypoalbuminaemia

Retrieved from https://www.huidziekten.nl/zakboek/dermatosen/ltxt/leukonychia.htm on 30th June 2023

BROWN LINES

a brown line close to the nail’s end may be present in patients with chronic renal failure

PALLOR

pallor of the skin creases may be a sign of anaemia
thalassemia major (a severe recessive genetic disorder of hemoglobin structure with hemolysis or rapid breakdown of red blood cells resulting in anemia and iron overload in the heart, liver and other organs), sickle cell disease (red blood cells become hard and sticky and look like a C-shaped farm tool called a “sickle”), iron deficiency (due to malnutrition or heavy menstrual bleeding or IBD, celiac disease, Vitamin B12 deficiency, folic acid) and leukaemia (malignant progressive disease in which the bone marrow and other blood-forming organs produce increased numbers of immature or abnormal leucocytes which suppress the production of normal blood cells) may all lead to anaemia and consequentially pallor of the skin creases

Retrieved from https://twitter.com/Jcortesizaguirr/status/1281723663553908743 on 3rd April 2023

PALMAR ERYTHEMA

redness involving the heel of the palm, and occasionally the fingers; symptoms include non-itching, symmetrical, painless, and slight warmth in redness areas
common in patients with liver disease, thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body), rheumatoid arthritis (chronic inflammatory disorder), but also possible in pregnant women due to hormonal changes

DUPUYTREN’S CONTRACTURE

thickening of the palmar fascia which causes flexion contracture commonly affecting the ring and little finger
commonly found in patients with chronic liver disease

FLAPPING TREMOR

ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
flapping tremor can be seen in patients with liver disease and chronic renal failure

Retrieved from https://medicinaonline.co/2019/09/02/asterissi-asterixis-in-neurologia-caratteristiche-significato-esecuzione/ on 3rd April 2023

3. EXAMINING THE EYES

PALLOR

pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl

JAUNDICE

yellowish discolouration of the sclerae, mucous membranes and skin due to high concentration of Bilirubin in the blood; easily detected in daylight but may be missed in artificial lighting

4. EXAMINING THE MOUTH

TONGUE

assess the patient’s tongue for dehydration (dry, coated tongue which looks white and furry)
pale and atrophic tongue can be seen in iron deficiency anaemia
beefy red and painful tongue can be seen when the patient is deficient in B12

BREATH SMELL

a ‘fishy’ breath smell indicates uaremia (raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys)
a ‘mousy’ breath smell indicates liver failure
a ‘fruity’ breath smell indicates presence of ketones in diabetic ketoacidosis
a ‘wine-like’ breath smell indicates renal failure
a ‘bad’ breath smell may also be caused by sleeping with an open mouth

5. PALPATING THE CERVICAL LYMPH NODES

Virchow’s node is an enlarged hard lymph node which can be found in the left supraclavicular fossa; it is indicative of abdominal neoplasm (abnormal growth that occurs within the abdomen)

Retrieved from https://casereports.bmj.com/content/2013/bcr-2013-200749 on 30th June 2023

6. EXAMINING THE PATIENT’S CHEST

SPIDER NAEVI

central spiral arteriole that supplies a radiating group of small blood vessels, which, if occluded by pressure, blanches
commonly found in the upper part of the body above the nipple line especially in areas exposed to sunlight
healthy people, including pregnant women and patients on oestrogen therapy may have one or two spider naevi, which is considered to be normal
a large number of spider naevi is commonly found in liver disease

examination of the abdomen — Retrieved from https://integrityskin.com.au/spider-naevi/ on 30th June 2023

PURPURA

purpura shows up when capillaries bleed into the skin
purpura commonly shows up in patients with a low platelet count caused by haematological malignancies or patients with chronic liver disease along with coagulation defects

GYNAECOMASTIA

gynaecomastia is enlargement of the breasts in males
can be discovered by feeling gently around the nipples
gynaecomastia may be caused by puberty, chronic liver disease, bronchial carcinoma, and drugs such as digoxin and spirinolactone

7. examining the abdomen

ABDOMEN QUADRANTS

SWELLING

swelling may be caused by the 5 F’s in Abdo Distention, namely fluid, fat, flatus, faeces or foetus
swelling may also be a sign of hepatomegaly, incisional hernia, or abdominal mass

EPIGASTRIC PULSATIONS

epigastric pulsations can be due to aortic pulsations in a thin patient or an aortic aneurysm (a balloon-like bulge in the aorta – see further below for more information on palpating for aortic aneurysm)

DISTENDED SURFACE VEINS

commonly found in portal hypertension, usually radiating from the umbilicus (Caput Medusae) and in obstruction of the inferior vena cava

Retrieved from https://radiopaedia.org/articles/caput-medusae-sign-portal-hypertension-2?lang=us on 30th June 2023

SCARS

a midline scar may indicate a gastroduodenal, pancreatic or spleen surgery
a right subcostal scar may indicate a cholecystectomy or appendicectomy
a suprapubic scar a.k.a. Pfannensteil incision may indicate pelvic surgery or cesarean section

STOMAS

an ileostomy can be found in the right iliac fossa as a spout of mucosa protruding from the abdominal wall with a continuous flow of effluent
a colostomy can be found in the left iliac fossa if permanent, or in the right hypochondrium or left iliac fossa if temporary; it is flat in appearance (mucosa is sutured to skin) with intermittent effluent

PERISTALSIS

PALPATION

ask patient if any abdominal discomfort is present, and if yes, where
ensure that your hands are warm
to palpate, use the flat surface of your fingers and keep your forearm at level with the abdominal wall
palpate the abdomen gently, leaving any painful areas for last; note any signs of pain on the patient’s face, rigidity, or tenderness
repeat palpation in a firmer deeper way, feeling for abnormal masses
if a mass is felt, note position, size, shape, surface (smooth or irregular), edge (clear or poorly defined), consistency, pulsatility, percussion note (dull or resonant), and presence of bowel sounds

PALPATION OF THE LIVER

to palpate the liver start in the right iliac fossa; when the patient breathes in and out, move your hand upwards bit by bit until you reach the costal margin
check for hepatomegaly (enlargement of the liver) and if present, note size in cm below the costal margin; hepatomegaly causes include metastases (eg. bowel carcinoma), congestive heart failure, cirrhosis (early stage), and infections (eg. viral hepatitis, infectious mononucleosis)
check liver edge – smooth edge may signify congestive heart failure; knobbly edge may signify metastases
check consistency – liver feels hard in the case of metastases
check for tenderness – happens when liver capsule is distended; indicates congestive heart failure, hepatitis or hepatocellular carcinoma
check for pulsatility – happens in the case of tricuspid regurgitation

PERCUSSION OF THE LIVER

start percussion of the liver further up from the fifth intercostal space and move down to the mid-clavicular line
the liver is dull to percussion
normal liver does not extend beyond 1 cm below the costal margin on deep inspiration

PALPATION OF THE SPLEEN

the spleen acts as a filter of the blood, filtering for bacteria, parasites, and fungi; the spleen has white blood cells to protect against septicaemia (infection of the blood)
start palpating the spleen from the right iliac fossa
as the patient breathes in and out, move your hand towards the tip of the tenth rib; on reaching the costal margin, place your left hand around the lower left rib cage and palpate with your right hand in the midaxillary line
a slightly enlarged spleen can best be felt if the patient half rolls over onto his right side
a large spleen would sound dull in percussion
MASSIVE splenomegaly can be caused by Myelofibrosis, Chronic graunlocytic leukaemia, and Malaria (parasitic infection)
MODERATE splenomegaly can be caused by Haemolytic anaemia, Chronic lymphocytic leukaemia, Lymphoma and Portal Hypertension
MILD splenomegaly can be caused by Infections such as glandular fever, hepatitis, brucellosis (from unpasteurised milk) and infective endocarditis, Pernicious anaemia, and Sarcoidosis
HEPATOSPLENOMEGALY is when both the liver and the spleen become enlarged; causes include Myelofibrosis, Portal Hypertension, Lymphoma, Leukaemia, and Infections

PALPATION OF THE KIDNEYS

the kidneys are usually not felt; only an enlarged kidney or enlarged spleen can be felt
palpate each kidney by positioning one hand behind the patient’s loin and the other just above the anterior superior iliac spine; instruct the patient to breathe deeply
normal kidneys usually give a tympanic sound when percussed
signs of renal swelling include: ballottable kidneys, vertical descent, moving down on inspiration, being resonant to percussion (due to overlying colon)
bilateral enlargement of the kidneys may happen due to polycystic kidney disease
unilateral enlargement of the kidneys may happen due to Hydronephrosis (kidney becomes stretched and swollen due to a build-up of urine inside them), simple renal cysts, or a tumour (renal cell carcinoma)
NOTE: thin patients may have a palpable right kidney lower pole

PALPATION FOR AORTIC ANEURYSM

aortic aneurysm is a balloon-like bulge in the aorta that can dissect or rupture
palpate for aortic aneurysm by placing two hands along the midline, just above the umbillicus; aortic aneurysm may be present if an expansile pulsation can be felt

THE GALL BLADDER

Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/gallbladder-scan on 1st July 2023

the gall bladder, which is situated just to the lateral side of the right rectus muscle adjacent to the 9th costal cartilage, is usually impalpable

PALPATING FOR OTHER MASSES

palpate for abnormal masses in the epigastric region which can be a sign of a gastric carcinoma or pancreatic cyst
palpate the suprapubic region for uterine fibroids
NOTE: in a normal patient, the descending colon is often palpable in the left iliac fossa

ASCITES EXAMINATION – only necessary if the abdomen is distended!

ascites is a condition in which fluid collects in spaces within the abdomen; it affects lungs, kidneys and other organs
check for shifting dullness by percussing over the abdomen, starting centrally and moving to the flanks; note change of percussion note from resonant to dull (dull = fluid); ask patient to roll over onto that side whilst holding your hand on that same position, then percuss the area and check if area of dullness has moved…if yes, this is a sign of shifting dullness
check for fluid thrill by asking a colleague to place the edge of his or her hand along the midline of the patient’s abdomen; flick one side while feeling the opposite side; if ascites is present, a wave-like sensation called fluid thrill may be felt hitting your hand
causes of ascites include: intra-abdominal neoplasms, liver cirrhosis with portal hypertension, carcinoma, and nephrotic syndrome

GROIN & EXTERNAL GENITALIA EXAMINATION

position your fingers over the inguinal and femoral orifices and feel for any masses at these sites; instruct the patient to cough and feel for a cough impulse and enlarged inguinal lymph nodes
causes of lumps in the groin include: inguinal or femoral hernia, vascular structures such as the saphena varix and femoral aneurysm, lymphadenopathy, ectopic testis in superficial inguinal pouch, undescended testis, lipoma or hydrocoele of the spermatic cord

Retrieved from https://www.keyholesurgeon.com.au/femoral-hernia-sydney-randwick.html

AUSCULTATING THE ABDOMEN

auscultate for bowel sounds and assess pitch; bowel sounds may be absent or decreased if patient has peritonitis, or in post-operative ileus presence (temporary lack of normal muscle contractions of the intestines); bowel sounds may be increased with a tinkling pitch in the case of bowel obstruction
auscultate along the course of the aorta and iliac arteries, and in the renal areas for any bruits (audible vascular sound associated with turbulent blood flow)

URINE TESTING

examine the patient’s urine with a dipstix and check for protein, blood and glucose

DIGITAL RECTAL EXAMINATION

instruct the patient to turn in the left lateral position
reassure and explain that the procedure may be uncomfortable but painless
wear gloves and lubricate the index finger
examine the perianal skin for skin lesions, external haemorrhoids or fistulae
place the tip of the forefinger on the anal margin, steadily pressing on the sphincter whilst passing the finger gently through the anal canal into the rectum
assess tone of anal sphincter and palpate around the entire rectum; note for any abnormalities and examine any masses systematically
in a male patient, feel for the prostate gland anteriorly; a normal prostate is smooth with a firm consistency, and has two lateral lobes separated by a median groove
prostatic hyperplasia commonly produces a palpable symmetrical enlargement
a hard and irregular prostate with an undetectable median groove is usually a sign of prostatic carcinoma
after withdrawing your finger, examine stool colour and check for presence of blood and mucus
NOTE: 50% of rectal carcinomas may be detected through a rectal examination

Liver Issues can also arise from excessive alcohol consumption, drug reaction, hepatitis A (from food), gallstone obstruction in bile duct. An Examination of the Abdomen can help detect Liver Disease.

Summary

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Examination of the Respiratory System

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the respiratory system.

Examination of the RESPIRATORY System Outline

looking out for sputum pots
examining the hands
examining the face
examining the neck
examining the chest wall

1. LOOKING OUT FOR SPUTUM POTS

look around for sputum pots at the patient’s bedside
if available, assess the quantity (large quantity may be a sign of bronchiestasis) and the character a.k.a. colour and consistency; haemoptysis (blood-streaked sputum) may be due to bronchial carcinoma, pneumonia, pulmonary infarction, bronchiestasis or tuberculosis; mucopurulent greenish-yellowish sputum may be due to a chest infection

2. EXAMINING THE HANDS

TAR STAINING

check for tar staining of the patient’s fingers – this would indicate that the patient is a smoker

Tar-Stained Fingers – Retrieved from https://escholarship.org/content/qt8ck911z0/qt8ck911z0.pdf on 21st March 2023

FINGER CLUBBING

check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)

PERIPHERAL CYANOSIS

can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
featured through bluish discolouration of the nail beds
usually starts showing when patient is at <85% SPO2

Cyanosis – Retrieved from https://www.physio-pedia.com/Cyanosis on 21st March 2023

FLAPPING TREMOR

ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
flapping tremor can be seen in patients with severe respiratory failure

HAND TEMPERATURE

warm hands signify vasodilation or carbon dioxide retention
cold hands signify vasoconstriction
note if hands are dry or moist
clammy hands may be a sign of anxiety or sympathetic activation

Clammy Skin – Retrieved from https://www.medicalnewstoday.com/articles/322446 on 21st March 2023

3. EXAMINING THE FACE

HORNER’S SYNDROME

if Horner’s Syndrome is present, the patient may have unilateral constriction of the pupil (miosis), partial drooping of the eyelid (ptosis), impaired sweating on the same size of the face, and enophthalmos (recession of the globe in the orbital fossa)
Horner’s Syndrome may be caused by an apical lung carcinoma infiltrating the sympathetic chain

PALLOR

CENTRAL CYANOSIS

can be easily noted when looking at the patient’s tongue
happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD

examination of the respiratory system — Central Cyanosis – Retrieved from https://www.researchgate.net/figure/Clinical-photograph-showing-central-cyanosis-Note-also-clubbing-of-fingers_fig3_255685646 on 23rd March 2023

4. EXAMINING THE NECK

JUGULAR VENOUS PRESSURE (JVP)

assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
normal JVP height = <4cm
high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction (non-palsatile)

CAROTID PULSE

feel the carotid pulse – a bounding pulse indicates carbon dioxide retention

SUPRACLAVICULAR LYPMH NODES

feel the patient’s supraclavicular lymph nodes
if enlarged, they may indicate carcinoma, lymphoma, sarcoidosis or tuberculosis

TRACHEA

feel the patient’s trachea; normally, the upper 4-5cm of the trachea can be felt between the cricoid cartilage and the suprasternal notch; compare distance to each side
a displaced trachea may result from moving away from a lesion eg. due to a superior mediastinal mass such as lymphoma or carcinoma, massive pleural effusion, or retrosternal goitre, or moving towards a lesion eg. due to upper lobe collapse or fibrosis

5. EXAMINING THE CHEST WALL

CHEST SHAPE

barrel chest is caused by an increase in the anteroposterior diameter relative to the lateral diameter of the chest wall. While the normal ratio is usually 5:7, patients with emphysema present with both measurements approximate; barrel chest may also be a sign of thoracic kyphosis (excessive curvature in the thoracic spine that leads to a rounded upper back)
thoracic kyphoscoliosis – a patient with kyphosis presents with an excessive outward curvature of the spine, causing the back to hunch; a patient with scoliosis presents with lateral deviation of the backbone caused by congenital or acquired abnormalities of the vertebrae, muscles and nerves; a patient with kyphoscoliosis presents with abnormal curvature of the spine both forwards and sideways, in other words, a combination of both kyphosis and scoliosis
pectus carinatum a.k.a. pigeon chest presents as localised prominence of the sternum and adjacent costal cartilages, commonly accompanied by indrawing of the ribs to form symmetrical horizontal grooves (Harrison’s sulci) above the usually everted costal margins; the deformities are thought to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state; pectus carinatum is common following chronic respiratory disease in childhood eg. severe asthma
pectus excavatum a.k.a. funnel chest is a developmental defect featuring either a localised depression of the lower end of the sternum, or depression of the whole length of the body of the sternum and of the costal cartilages attached to it; while this is usually asymptomatic, an increased degree of depression of the sternum may cause the heart to become displaced to the left, restricting the ventilatory capacity of the lungs
iatrogenic chest is the result of former treatment for pulmonary tuberculosis with thoracoplasty, which involves surgical removal of parts of the ribs, allowing the chest wall to fall in and collapse the affected lung

Barrel Chest – Retrieved from https://www.facebook.com/medicine.in.picture/photos/a.724168341072410/1168811979941375/?type=3 on 6th April 2023

Kyphoscoliosis – Retrieved from https://en.wikipedia.org/wiki/Kyphoscoliosis on 6th April 2023

SKIN

look for scars from previous trauma, surgery, etc.
look for evidence of radiotherapy eg. ink marks and telangiectasia (small, widened blood vessels on the skin, sometimes spidery in appearance, which blanche on pressure)
look for subcutaneous nodules eg. metastases

RESPIRATORY MOVEMENTS

rate of respiration is normally between 14-18 bpm; tachypnoea is noted in acute pulmonary infections (especially if accompanied by pleural pain), bronchial asthma, pulmonary embolism and acute pulmonary oedema
mode of breathing – when breathing, women tend to use the intercostal muscles more than the diaphragm, with their respiratory movements being predominantly thoracic; men tend to rely more on the diaphragm, with their respiratory movements being predominantly abdominal; lack of chest expansion may be caused by ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse), intercostal paralysis (causes reduced vital capacity, inability to cough, and high mortality) or pleural pain; breathlessness is usually accompanied by respiratory distress, increased respiratory frequency and abnormal respiratory movements
abnormal inspiratory movements – use of accessory muscles – sternomastoids, scaleni and trapezii, in-drawing of the suprasternal and supraclavicular fossae, intercostal spaces and epigastrium can be observed with each inspiration; paradoxical movements within the chest may indicate mobile fractures within the thoracic cage – these can cause serious issues such as respiratory distress and hypoxaemia due to interfering with pulmonary ventilation
abnormal expiratory movements – commonly caused if the elastic recoil of the lungs are insufficient in completing air expansion from the alveoli, as in emphysema or asthma; patients exhibiting these symptoms tend to prefer leaning slightly forward in an attempt to augment their expiratory efforts, at times exhaling through pursed lips
expansion of the chest wall – unilateral reduction of chest wall movement may be caused by pleural effusion, pneumothorax, lung consolidation (as in pneumonia, tuberculosis, neoplasm or infarction), lung collapse / lobectomy or pneumonectomy, and fibrosis (as seen in pulmonary tuberculosis); generalised restriction of chest wall movement may be seen in emphysema, bilateral pleural effusion, and ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse)

MEDIASTINAL DISPLACEMENT

determine the position of the apex beat, which also reflects the position of the lower mediastinum; pleural effusion and pneumothorax may cause mediastinal displacement (pushed away); fibrosis, collapse, and pneumonectomy may cause mediastinal displacement (pulled towards)

TACTILE VOCAL FREMITUS

tactile vocal fremitus is the palpable vibration transmitted through the bronchiopulmonary system to the chest wall when the patient makes a deep vocal sound
fremitus is increased in consolidated areas within the lungs
fremitus is decreased when the bronchus is obstructed or the pleural space is filled by fluid, air or solid tissue eg. pleural effusion, pneumothorax or fibrosis

PERCUSSION

percussion is performed to compare the degree of resonance over equivalent areas on both sides of the chest, moving systematically from top to bottom

AUSCULTATION

auscultate over each lung segment whilst patient breathes in and out gently through mouth
note the character of the breath sound – diminished vesicular breath sounds may be caused by a generalised reduction in airflow eg. emphysema or tumour obstructing a bronchus, pleural effussion or pneumothorax; bronchial breath sounds in which both inspiration and expiration may sound as blowing in character, may be caused by consolidations, fibrosis or collapse
listen for added sounds such as rhonchi (wheezes – generalised: due to asthma, chronic bronchitis, emphysema, pulmonary congestion caused by left ventricular failure; localised: due to local bronchial obstruction due to carcinoma, lymph node or foreign body), crepitations (crackles – fine crackles due to lung fibrosis, pulmonary oedema or pneumonia; coarse crackles due to chronic bronchitis or bronchiectasis), pleural friction rub (creaking sound due to pneumonia and pulmonary infarct), and pneumothorax click (rhythmical sound synchronous with cardiac systole)
notice the character and intensity of vocal resonance – diminished vocal resonance is heard in pleural effusion, pneumothorax and collapse; increased vocal resonance is heard as a louder and clearer transmission of sound, commonly indicative of consolidation; in whispering pectoriloquy, the whisper is heard clearly with a stethoscope if there is consolidation, but is not heard if there is no consolidation; egophony is tested by asking the patient to say EEE aloud…if EEE sounds more like an A, consolidation may be present
palpate for axillary lymphadenopathy which can be felt in patients with lymphoma and mestastases

Examination of the Respiratory System for Common Respiratory Problems

Disease	Mediastinal Shift	Tactile Vocal Fremitus / Vocal Resonance	Percussion Note	Auscultation
Consolidation	None	Increased	Dull	bronchial breath sounds, crackles, bronchosphony, egophony, whispered pectoriloquy
Chronic Bronchitis	None	Normal	Resonant	normal to decreased breath sounds, wheezes
Emphysema	None	Decreased	Hyper-Resonant	decreased intensity of breath sounds usually with prolonged expiration
Asthma	None	Normal to Decreased	Resonant to Hyper-Resonant	wheezes
Pleural Effusion	Away	Diminished	Stony Dull	decreased to absent breath sounds, bronchial breathing and bronchophony, egophony, whispering pectoriloquy above effusion over the area of compressed lung
Pneumothorax	Away	Diminished	Hyper-Resonant	absent breath sounds, possible click
Fibrosis	Towards	Diminished	Dull	late inspiratory fine crackles
Pulmonary Oedema	None	Normal	Resonant	crackles at the bases of the lungs, possible wheezes

Summary

Step-by-step examination of the respiratory system:

sputum sample examination – quantity & character
examine hands for flapping tremor, temperature, sweat, pallor, peripheral cyanosis, finger clubbing, nail swing, tar staining
check pulse
check respiration rate
check blood pressure
examine eyes for horner syndrome
observe face for signs of central cyanosis, pursed lip breathing, nose flaring
observe neck for JVP height, enlarged supraclavicular lymph nodes, trachea displacement
observe chest (lungs) for scars, evidence of radiotherapy, subcutaneous nodules, pectus excavatum, pectus carinatum, kyphosis, accessory muscle use for breathing
check for chest expansion, determine position of apex beat, and perform tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance)
percuss chest (lungs) over intercostal spaces and compare sides
auscultate chest (lungs) and check for bronchial sounds, wheezing, crackles, pleural friction rub, or pneumothorax click
repeat tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance), percussion and auscultation at the patient’s back
perform whispering pectoriloquy (whispering ninety-nine) if suspecting consolidation
assess under arms for enlarged lymph nodes in axilla

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Examination of the Cardiovascular System

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the cardiovascular system.

Examination of the Cardiovascular System Outline

general considerations
examining the hands
examining the radial pulse, rhythm & rate
measuring the blood pressure
examining the face
examining the neck
examining the chest wall
examining the bases of the lungs
examining the abdomen
examining the lower limbs

1. General Considerations

If you haven’t done so already, introduce yourself and shake hands with your patient
Note the patient’s age and general state
Ensure that the examination room is quiet enough to perform auscultation
The patient should be properly undressed for this examination
The patient should be positioned adequately i.e. reclining at 45° with the head resting comfortably on pillows

2. Examining the Hands

FINGER CLUBBING

caused by interstitial oedema and dilation of the arterioles and capillaries
assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage).

examination of the cardiovascular system — Finger Clubbing – Retrieved from https://en.wikipedia.org/wiki/Nail_clubbing on 21st March 2023

PERIPHERAL CYANOSIS

can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
featured through bluish discolouration of the nail beds
usually starts showing when patient is at <85% SPO2

SPLINTER HAEMORRHAGES

featured as small dark subungual petechiae
may be symptoms of infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart) as well as trauma

TAR-STAINED FINGERS

caused by smoking – smoking accellerates build-up of atherosclerosis which leads to CVA and/or peripheral vascular disease and ischaemic heart disease. Complete occlusion by athersclerosis causes a Myocardial Infarction.

TEMPERATURE

warm hands signify vasodilation
cold hands signify vasoconstriction
note if hands are dry or moist
clammy hands may be a sign of anxiety or sympathetic activation

3. Examining the Radial Pulse, Rhythm & Rate

ASSESSING THE RADIAL PULSE

the radial pulse can be located just lateral to the flexor carpi radialis
assess the rhythm – sinus (normal – controlled by the sino-atrial node)? irregular (due to atrial or ventricular extrasystoles, atrial fibrillation or heart block)?
assess the rate – 60-100bpm at rest = normal; >100bpm = sinus tachycardia (due to fever, exercise, anxiety, heart failure); fast arrhythmias (due to atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia); <60bpm = bradycardia (due to high vagal tone in athletes, sleep, or certain medication eg. beta blockers or calcium antagonists)
assess the condition of the vessel wall – if vessel wall feels stiff and tortuous, atherosclerosis is probably present

4. Measuring the Blood Pressure

TAKING THE PATIENT’S BLOOD PRESSURE

the patient should not eat, smoke, take caffeinated products, or perform vigorous exercise for 30 minutes prior to the examination
the room should be quiet and adequately prepared so that the patient is comfortable
the patient’s arm should be positioned in a way so that the antecubital fossa is level with the heart
the bladder of the cuff should be centered over the brachial artery about 2cm above the antecubital fossa; the bladder length should not be less than 80% of the patient’s arm circumference
patient’s arm should be slightly flexed at the elbow
palpate the radial pulse and inflate the cuff until the pulse cannot be palpated any more, take note of the number displayed and deflate the cuff
place the stethoscope over the brachial artery
inflate the cuff to 30mmHg over the estimated systolic pressure
release the pressure slowly at about 5mmHg/second
note the measurement where you start hearing the korotkoff sound as the systolic pressure
note the measurement where you stop hearing the korotkoff sound as the diastolic pressure
record the patient’s blood pressure as systolic over diastolic
retake blood pressure measurement by repeating the same process on the other arm if the patient is visiting for the first time; if there is a difference in blood pressure of more than 10mmHg in one arm, record the highest reading

Category	Systolic	Diastolic
Normal	<130	<85
High Normal	130-139	85-89
Mild Hypertension	140-159	90-99
Moderate Hypertension	160-179	100-109
Severe Hypertension	180-209	110-119
Crisis Hypertension	>210	>120

Blood Pressure Classification in Adults

ASSESSING THE PULSE PRESSURE

pulse pressure is the difference between the systolic and diastolic blood pressure
a normal value of the pulse pressure falls somewhere between 30-40mmHg
a narrow pulse pressure may be a sign of reduced cardiac output such as in a haemorrhagic shock, as well as in severe aortic stenosis (prevents aortic valves from opening and closing properly, leading to stress on the heart to work harder to pump blood to the rest of your body), constrictive pericarditis (a condition in which granulation tissue formation in the pericardium results in loss of pericardial elasticity leading to restriction in the ventricular filling), and pericardial effusions (acute or chronic accumulation of fluid within the pericardial space)
a wide pulse pressure may be a sign of increased cardiac output and low vascular resistance, common in aortic insufficiency (heart valve disease where the aortic valve no longer functions adequately to control the flow of blood from the left ventricle into the aorta), anaemia (a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal), and thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body)

PULSUS PARADOXUS

pulsus paradoxus is the difference between where the Korotkoff sounds are first heard on expiration only and where they are heard on both inspiration and expiration is normally 10mmHg
pulsus paradoxus is present when the difference exceeds 10mmHg
pulsus paradoxus is associated with pericardial effusion (acute or chronic accumulation of fluid within the pericardial space) and severe acute asthma

5. Examining the Face

CENTRAL CYANOSIS

can be easily noted when looking at the patient’s tongue
happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD

ANAEMIA

anaemia is characterised by a reduction of haemoglobin concentration in the blood, which usually are <13.5g/dl in adult males and <11.5g/dl in adult females
anaemia can be noticed as pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl

CORNEAL ARCUS

corneal arcus is characterised by a greyish line in the periphery of the cornea, concentric with the edge but separated from it by a clear zone, consisting of cholesterol crystals
corneal arcus is typically seen in the elderly, but when seen in young people, it may be a sign of hypercholesterolaemia

XANTHELASMA

xanthelasma is characterised by intracutaneous yellow cholesterol deposits around the eyes
xanthelasma can be noted in normal people as well as in those with hypercholesterolaemia

MALAR FLUSH

malar flush is characterised by redness of the cheeks
malar flush is commonly seen in patients with mitral stenosis (narrowing of the valve between the two left heart chambers) as well as in normal individuals

6. Examining the Neck

JUGULAR VENOUS PRESSURE (JVP)

the jugular veins, which are located adjacent to the superior vena cava, directly reflect right arterial pressure
assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
normal JVP height = <4cm
high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction
note the waveform: a wave signifies right atrial systole whilst an absent waveform may be due to atrial fibrillation; c wave, which is rarely noted, is due to tricuspid valve closure; x descent (systolic collapse) is a sign of atrial relaxation and downward displacement of the tricuspid valve towards the right ventricular apex in ventricular systole; v wave is due to right atrial filling; y descent (diastolic collapse) is a sign of a fall in right atrial pressure when the tricuspid valve opens
giant a waves happen when the right atrium is contracting against resistance as in tricuspid stenosis; cannon a waves happen when the right atrium is contracting against a closed tricuspid valve as in complete heart block
the hepatojugular reflux helps in re-checking an already raised jugular venous pressure; it is done by pressing with the flat of the hand over the liver and watching the rise of the JVP

Jugular Venous Pulse – Retrieved from https://sketchymedicine.com/2015/05/jugular-venous-pulse-jvp/ on 24th March 2023

THE CAROTID PULSE

the carotid pulse is the closest point to the heart where the arterial pulse can easily be felt
note the waveform of the pulse: slow rising pulse = moderate to severe aortic stenosis; collapsing pulse = aortic incompetence; double peak pulse a.k.a bisferiens = moderate aortic stenosis with severe incompetence
assess the pulse volume: small volume = low cardiac output; large volume = anaemia or thyrotoxicosis

7. Examining the Chest Wall

SCARS FROM PAST SURGERIES

left infra-mammary scar is a sign of past closed mitral valvotomy
central sternal scar is a sign of past open heart surgery

APEX BEAT

determine the position of the apex beat, which is the lowest and outermost point of definite cardiac pulsation; the apex is usually found in the 5th intercostal space within the mid-clavicular line
the apex beat may be impalpable in individuals with COPD and in patients with obesity
the apex may be displaced due to ventricular enlargement following cardiac failure, pneumothorax and scoliosis
assess the quality of the cardiac impulse: normal = brief outward movement at the onset of left ventricular ejection; abnormal = thrusting displaced apex beat in volume overload due to active large stroke volume ventricle caused by mitral or aortic incompetence, sustained apex beat in pressure overload due to aortic stenosis and gross hypertension with a normal or reduced stroke volume; or parasternal heave in central thrust or lift in the sternal region or 3rd or 4th intercostal space indicating right ventricular hypertrophy
assess for palpable murmurs a.k.a. thrills or palpable heart sounds at the apex and base of heart; systolic thrill at apex = due to a ventricular septal defect or mitral regurgitation; systolic thrill at base = due to aortic or pulmonary stenosis; diastolic thrill at the apex = mitral stenosis; diastolic thrill at the base = aortic regurgitation; palpable first heart sound (sounds like a tapping apex beat) = felt in mitral stenosis; palpable pulmonary sound = felt in pulmonary hypertension

PRAECORDIUM AUSCULTATION

prior to auscultation of the parecordium, ensure surrounding area is quiet
use the diaphragm of the stethoscope to filter out low pitched sounds and identify high pitched sounds eg. 2nd heart sound
use the bell of the stethoscope to listen to low-pitched sounds eg. mitral stenosis murmur
aortic valve = best heard at the right 2nd intercostal space close to the sternum; pulmonary valve = best heard at the left 2nd intercostal space close to the sternum; tricuspid valve = best heard at the left 3rd, 4th and 5th intercostal spaces close to the sternum; mitral valve = best heard at the apex
heart sound S1 = closing mitral and tricuspid valves + upstroke of carotid pulse; loud S1 = mitral stenosis; faint S1 = mitral regurgitation; intensity variation = atrial fibrillation
heart sound S2: loud S2 = systemic or pulmonary hypertension; soft S2 = calcified or immobile aortic or pulmonary valve; fixed splitting S2 = atrial septal defect; reversed splitting S2 on expiration = delayed aortic component follows pulmonary component; fixed splitting S2 on inspiration = aortic component superimposed on the normal pulmonary component, usually in left bundle branch block (delay in the activation of left ventricle)
extra heart sounds: S3 = low-pitched sound following S2 which happens in rapid ventricular filling in early diastole (physiologically heard in children, healthy young adults, athletes, and in pregnancy; pathologically heard in patients with large poorly contracting ventricle or with increased ventricular stroke volume due to a leaking heart valve)
extra heart sound: S4 = soft low-pitched sound occurring just before S1 in rapid emptying of a hypertrophied atrium, always abnormal, commonly associated with severe heart failure and/or hypertension

AUSCULTATING FOR MURMURS

heart murmurs are music-like sounds caused by turbulent blood flow in the heart; murmurs can result from normal blood volume passing through an abnormal valve, or from increased blood volume passing through a normal valve
assess murmur timing – is it systolic or diastolic? (you may compare with the carotid pulse, and if murmur accompanies the pulse would be systolic, while if it follows the pulse it would be diastolic)
ejection systolic murmurs start after the 1st heart sound, increase in amplitude to a peak around mid-systole, and quiet down towards the end of systole, stopping completely before the 2nd heart sound; causes include aortic stenosis, pulmonary stenosis (normal volume of blood flowing through a narrowed valve), and pregnancy (due to increased blood volume flowing through a normal valve)
pansystolic murmurs extend throughout systole to the 2nd heart sound; causes include mitral or tricuspid valve leakage, or a ventricular septal defect
late systolic murmurs are variants of the pansystolic murmurs, but these do not start right after the first heart sound but later on in systole; common in mitral valve prolapse
early diastolic murmurs start right after the 2nd heart sound and quiet down as diastole proceeds; causes include aortic and/or pulmonary regurgitation
mid-diastolic murmurs are low-pitched rumbling sounds best heard with the stethoscope bell at the apex of the heart while the patient is rolled onto the left hand side; occurs in mitral stenosis and rarely in tricuspid stenosis
continuous murmurs are heard during systole and diastole; occur in patients with ductus arteriosus (channel connecting the aorta and pulmonary artery, which normally closes after birth)
assess murmur intensity – murmur intensity is measured by grades…Grade 1 = heard by an expert in optimum conditions; Grade 2 = heard by a non-expert in optimum conditions; Grade 3 = easily heard, no thrill; Grade 4 = loud murmur with a thrill; Grade 5 = very loud, commonly heard over a wide area, with a thrill; Grade 6 = extremely loud, heard without a stethoscope
assess murmur site and radiation – aortic stenosis = to the upper right sternal edge and neck; aortic rugurgitation = down the left sternal border and towards the apex; mitral stenosis = localised to the apex; pulmonary stenosis = to the upper left sternal border and beneath the left clavicle; pulmonary regurgitation = down the left sternal border; tricuspid stenosis = localised to the lower left sternal border; tricuspid regurgitation = lower left and right sternal border and epigastrium; ventricular septal defect = lower sternal edge
assess murmur pitch – high pitch = greater pressure gradient; aortic incompetence murmur is high pitched so it is best heard with the diaphragm of the stethoscope; mitral stenosis murmur is low pitched so it is best heard with the bell of the stethoscope

AUSCULTATING FOR ADDED SOUNDS

ejection click = opening sound caused by thickened aortic and pulmonary valves; happen right after first heart sound and before any ejection murmur
prosthetic heart valves = usually have a quiet opening sound and a louder closing sound, seemingly metallic in character
pericardial rub = friction sound common in acute pericarditis, usually heard by the diaphragm of the stethoscope left of the lower sternum with the patient breathing out, with intensity varying from hour to hour and with patient positioning

8. Examining the Bases of the Lungs

crackes indicate pulmonary oedema, since they are produced by the explosive re-opening of collapsed airways

9. Examining the Abdomen

palpate for the liver – enlarged liver is a sign of right heart failure; enlarged and pulsatile liver is a sign of tricuspid regurgitation
palpate for aortic aneurysm – felt as a pulsatile mass over the epigastrium; a bruit may also be heard over it

10. Examining the Lower Limbs

PALPATE FOR THE PERIPHERAL PULSES

femoral pulse = midway between the symphysis pubis and the anterior superior iliac spine
popliteal pulse = deep in the popliteal fossa
dorsalis pedis artery = along the cleft between the first two metatarsals
posterior tibial artery = half-way along a line between the medial malleolus and the prominence of the heel
NOTES: always compare left and right sides; always listen for bruits at all sites on both sides (heard over narrowed arteries); if peripheral pulses are impalpable, the problem may be peripheral vascular disease

Peripheral Pulses – Retrieved from https://www.brainkart.com/article/Assessment-of-Vascular-Disorders–Health-History-and-Clinical-Manifestations_31948/ on 30th March 2023

ASSESS FOR SACRAL & LOWER LIMB OEDEMA

oedema is the result of increased interstitial fluid that causes swelling of the tissues
subcutaneous oedema can be determined by pitting of the skin following firm pressure applied by a finger or a thumb for a few seconds

Examination of the Cardiovascular System

Summary

Step-by-step instructions on how to perform an examination of the cardiovascular system:

assess hands for finger clubbing, peripheral cyanosis, tar staining
assess face for yellow lesions close to the inner eyes, malar flush, central cyanosis
assess neck: palpate the carotid artery & determine pulse rate, rhythm and volume; calculate CVP
assess chest: determine apex beat placement
auscultate for heart sounds and murmurs
check pedal pulses and for pitting oedema

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Introduction to Patient Assessment and Implementation of Care

Patient assessment and implementation of care requires a systematic history-taking approach, which has to be professional yet able to gain the patient’s confidence and trust. Acquired patient history should include all information relevant to the illness in question, as well as general information about the patient and his or her background, social situation and other problems. Patient assessment should be carried out in a holistic way.

History-Taking Basic Principles

Ensure that the interview with the patient is taking place in an appropriate, comfortable and private setting
Introduce yourself and shake hands with the patient
Address and remember the patient with his or her name
Treat with respect and courtesy

Basic History-Taking Outline

presenting complaint history
medical & surgical history
drug history
family history
social history
systematic enquiry

1. Presenting Complaint History

Acquire basic information such as client’s full name, age and address
Establish the nature and duration of the presenting complaint – when did it start? how? try to acquire the chronological order of main symptom/s onset
Obtain duration, onset (was it sudden or gradual?), continuation (constant or periodic? frequency? improving or progressing?), precipitating or relieving factors, and associated symptoms eg. feeling lightheaded, out of breath, or sweaty
If pain is a symptom, determine site, radiation, character (ache? pressure? shooting pain? stabbing pain? dull pain?) and severity (does it stop you from functioning as normal? does the pain wake you up from your sleep?); pain originating from organs is usually dull and compressive, while pain originating from the surface is usually sharp

2. Medical & Surgical History

Previous illnesses
Previous admissions to hospital
Previous surgeries (keep in mind that recent surgery may lead to Pulmonary Embolism)
Other comorbidities eg. diabetes mellitus, hypertension, hyperlipidaemia, fits, CVAs, heart disease and psychiatric illness

3. Drug History

Obtain names of all medications that the patient is taking, including over-the-counter drugs, herbal medicines and laxatives
Determine each drug’s dose, administration frequency, and compliance
Ask about any known drug allergies or suspected reactions

4. Family History

Obtain information about any genetic diseases eg. beta thalassaemia
Obtain information about other diseases eg. hypertension and coronary artery disease which are influenced more with predisposed environmental factors eg. diet and smoking; in the case of heart disease ask about whether the patient’s parents, siblings or children have experienced heart disease

5. Social History

Ask about the patient’s home environment especially where the patient has mobility or cardio-respiratory problems; determine the number of people living together in the house, the number of rooms, any need for bathroom arrangements, heating (or lack of), steps leading to the house, steps inside the house, and the possibility of the patient sleeping on ground-floor level
Ask about the patient’s occupation, taking note of any possible exposure to substances related to the patient’s presenting symptoms; unemployment may be a predisposing factor for mental and physical problems; occupation history may provide an insight to the patient’s financial situation
Ask the patient about personal interests; lack of interests may lead to lack of lifestyle appreciation
Ask about any habits that may impact the patient’s health eg. alcohol abuse (including quantity of alcohol consumption per day or week – regular consumption of more than 21 units of alcohol per week in males or 14 units in females pose a significant risk of developing alcohol-related disorders such as liver cirrhosis and pancreatitis, as well as hypertension); if patient is a heavy drinker, determine consumption quantity, age of onset of drinking, amount of money spent on alcohol per week, previous drinking habits, related hospital admissions, time of a typical day’s first alochol consumption, and whether drinking happens mostly at home or in a particular place
Ask about smoking habits, and if present, determine how many cigarettes does the patient smoke daily, as well as age of onset of smoking
Ask about drug abuse, and if present, what type of drug is being used, mode of administration, any sharing of needles, status of hepatitis and HIV, age of onset of drug use, and reason for using drugs

6. Systematic Enquiry

Enquire about any other symptoms that may indicate any other unsuspected disease; the following checklist may help…

Cardiovascular Symptoms

– chest pain on exertion

– orthopnoea (breathlessness when lying flat)

– paroxysmal noctournal dyspnoea (nocturnal breathlessness attacks)

– palpitations

– ankle swelling

– pain in legs upon exertion

Respiratory Symptoms

– shortness of breath upon exertion

– wheezing

– coughing

– sputum (note colour and amount)

– haemoptysis (blood-stained sputum)

– chest pain in relation to respiration or coughing

Gastroenterological Symptoms

– mouth condition (check for tongue infection or bleeding gums)

– dysphagia (difficulty swallowing)

– indigestion

– heartburn

– abdominal pain

– weight loss

– change in bowel habits

– stool colour (pale, tarry black, bloody)

Urogenital Symptoms

– dysuria (pain on passing urine)

– urine-passing frequency during the day and night

– haematuria (blood in urine)

– number of sexual partners

CNS-Related Symptoms

– headaches

– fits

– parasthaesia (tingling)

– numbness

– muscle weakness

– hearing problems (eg. deafness, tinnitus)

– excessive thirst

– sleep patterns

Vision-Related Symptoms

– appearance of the eyes

– vision disturbance

– pain

Locomotor Symptoms

– joint pain or stiffness

– muscle pain or weakness

Endocrine System Symptoms

– heat or cold intolerance

– change in sweating

– prominence of the eyes

– swelling of the neck

Male-Related Symptoms

-prostatic symptoms (difficulty in starting/passing urine, poor stream, post-micturition dribbling)

– erections, ejaculation, frequency of intercourse, urethral discharge

Female-Related Symptoms

– pre-menopausal (age of onset of periods, regularity, length, blood loss, contraception, and vaginal discharge)

– post-menopausal bleeding

– stress and urge incontinence

– libido and pain during intercourse

Concluding the History

ask the patient whether he or she would like to add anything else
summarise information given and allow the patient to correct you if or where you are wrong
by analysing the collected information, you may now be able to reach a provisional diagnosis and emphasise on the related physical examination components for patient assessment continuation.

NOTE: when starting a patient assessment, while gathering the patient’s history, it is important to use selective questions to clarify information being relayed, however, do not suggest symptoms or answers to the patient, as that may lead to inaccurate information.

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