Some portions of the examination may be best performed while sitting up (such as a neck bruit), while other portions may be best performed while lying back at a 30- or 45-degree angle (such as hepatojugular reflux.) Some portions (such as the heart sounds) may be evaluated in both positions, while others (such as the carotid artery auscultation) may be done in either.
Certain conditions can be identified upon inspection.
Phrases in the writeup can include:
- heart rate and rhythm: "regular rate and rhythm" or "RRR"
- heart sounds: "+S1, S2"
- murmurs, rubs, and gallops: "no m/r/g"
- point of maximal impulse: "PMI nondisplaced"
More detailed notes may mention heaves and bruits. Peripheral pulses may be included in a cardiovascular system or in a "Extremities" section.
- The Journal of Clinical Examination - A useful online source for evidence-based guidance on physical examination
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