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The Cardiovascular Exam

Examination of the cardiovascular system is easy to learn but difficult to master. Careful inspection and palpation for peripheral findings, coupled with attentive auscultation of the praecordium, may allow for clinical diagnosis of a patient's cardiac pathology prior to any further investigations.
The Patient
Hands
Arms
Head
Neck
Chest Inspection
Chest Palpation
Chest Auscultation
Back
Abdomen
Legs
 

The Cardiovascular Exam

On this page:First StepsThe PatientHandsArmsHeadNeckChest Inspection & PalpationChest AuscultationBackAbdomenLegsFinishing Up

Overview

  • Examination of the cardiovascular system is easy to learn but difficult to master. Careful inspection and palpation for peripheral findings, coupled with attentive auscultation of the praecordium, may allow for clinical diagnosis of a patient's cardiac pathology prior to any further investigations.
  • When performing a cardiovascular examination, always try to get to the chest as quickly as possible.

First Steps

  • Before commencing the cardiovascular exam, wash your hands, introduce yourself to the patient and gain consent.
    • First Steps
  • Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination.
  • Always stand on the right side of the bed during the cardiovascular examination.

The Patient

    • Inspect the Room

      Look around the room, as this can provide clues regarding the patient’s diagnosis:
    • Cigarrettes are a sign of smoking, a significant cardiovascular risk factor.
    • Oxygen delivery suggests that the patient is hypoxic; this may for several reasons including pulmonary oedema or pulmonary hypertension.
    • GTN spray suggests that the patient has ischaemic heart disease.
    • Intravenous antibiotics in a patient with a murmur suggest infective endocarditis.
    • Any other medications that the patient may be taking, including intravenous infusions, puffers or tablets, may provide additional information.
  • Generally inspect the patient, taking note of their age, gender and general comfort.
    • Measures of body habitus include:
    • The body mass index (BMI) - assesses the patient's weight in the context of their height, allowing for a more accurate measurement (with several limitations).
    • The waist circumference and waist-hip ratio are markers of central obesity, with evidence to support their use in estimating cardiovascular risk.
  • Look for obvious dysmorphic facies - signs suggestive of congenital syndromes such as Marfan syndrome, Down syndrome and Turner’s syndrome - as these conditions are associated with cardiovascular disease.

    • Skin Colour

    • Look at the colour of the patient’s skin for pallor or cyanosis.
  • Skin pallor is classically a sign of anaemia, though may also occur due to low output or peripheral shutdown.
  • Cyanosis is a blue discolouration of the skin and mucous membranes - this may be either peripheral or central and suggests either severe hypoxia, or severe peripheral shutdown.

    • Fluid Status

    • Assess whether the patient is dehydrated, euvolaemic or fluid overloaded.
  • Dehydration occurs in the setting of poor oral intake or fluid loss (e.g. due to diarrhoea, vomiting, sweating or diuresis). Signs of dehydration include tachycardia, poor urine output, dry mucous membranes and reduced skin turgor.
  • Fluid overload may occur in the context of several conditions including, heart failure, renal failure, liver cirrhosis, SIADH, pregnancy or simply due to excessive IV fluid administration. Signs of fluid overload include bounding pulses, raised JVP, pulmonary crepitations and pitting oedema.

Hands

    • Clubbing

    • Look at the digits for evidence of clubbing, or enlargement of the distal segments of the fingers / toes. This is classically associated with respiratory pathology such as cancer or chronic lung infection, though may also occur with cyanotic congenital heart disease and liver cirrhosis.
    • Hands

    • Capillary Refill

    • Press on the patient’s nail and count how long it takes for colour to return to the nail. A reduced capillary refill time of <2 seconds is classically a marker of poor perfusion, however this test is highly variable in adults.

Arms

    • Injection Sites

    • Track marks on a patient's arm suggest IV drug use, which is a strong risk factor for bacterial septicaemia and infective endocarditis.

    • Radial Pulse

    • Palpate the patient’s radial pulse for heart rate and rhythm. Count the heart rate over at least 30 seconds and multiply to estimate beats per minute.
  • Note whether the pulse is regular, regularly irregular or irregularly irregular. The implication of an irregularly irregular pulse is likely atrial fibrillation; remember that this is associated with valvular (particularly mitral) pathology.
    • Arms

    • Radial Pulse Delay

    • Next, palpate both radial pulses at once to assess for radio-radial delay. If the left radial pulse is slightly later than the right, then this suggests aortic coarctation. Radio-femoral delay may also be assessed for, though ensure that you ask the patient and examiner prior to testing for this.
    • Arms

    • Respiratory Rate

    • While ostensibly still measuring the pulse, count the patient’s respiratory rate over 30 seconds. Resp rate is a sensitive marker of deterioration in hospitalised patients and both tachypnoea (fast resp rate >20) and bradypnoea (slow resp rate <12) are concerning signs.

    • Blood Pressure

    • Always offer to measure the patient’s blood pressure.
    • Arms
  • The cuff should measure ~80% of the patient’s arm circumference; inflate the cuff to 30mmHg beyond where the pulse is no longer palpable, then slowly deflate until the beating sound is first heard (this is the systolic blood pressure). Then deflate until the beating sound disappears entirely (this is the diastolic blood pressure). Never check the blood pressure on an arm with an AV fistula or axillary clearance for breast cancer.
  • Hypertension (increased BP >140/90) may have primary or secondary causes, and is associated with increased risk of both acute and chronic cardiovascular complications. Hypotension (reduced systolic BP <100mmHg) is associated with postural hypotension, cardiac disease, hypovolaemia and shock.
  • Note the patient’s pulse pressure, or the difference between the systolic and diastolic blood pressure. A narrow pulse pressure is a sign of severe aortic stenosis, severe mitral stenosis or hypovolaemia. A widened pulse pressure (often along with a collapsing pulse) is a sign of aortic regurgitation or patent ductus arteriosis.
  • For a detailed guide, please visit our blood pressure page.

    • Collapsing Pulse

    • Next, feel for collapsing pulse. This can be thought of as palpably widened blood pressure, in the context of aortic regurgitation or patent ductus arteriosis. First ask the patient if they have any pain in their left shoulder, then lift their left shoulder up while palpating the radial pulse. Feel for a strong pulse with sudden drop in intensity following its peak.
    • Arms

    • Abnormal Facies

    • Look at the patient’s face for evidence of mitral facies: a rosy complexion of the cheeks with patches of blue discolouration, - a classical sign of mitral stenosis.
    • Head

    • Fundoscopy

      When performing the cardiovascular exam, always offer to perform fundoscopy - though recognise that the yield will likely be low in a patient without a dilated pupil. Look for:
    • Hypertensive eye changes such as silver wiring, arteriovenous nicking, flame-shaped haemorrhages, cotton wool spots and papilloedema.
    • Roth spots - pale patches on the retina with a ring of surrounding haemorrhage, and are a sign of infective endocarditis.
  • Or, at least, mention that you would look for those things.

    • The Mouth

    • Look in the patient’s mouth. Note their dentition (the condition of their teeth), as poor dentition is associated with risk of bacteraemia and infective endocarditis. Look for the high-arched palate of Marfan syndrome.

    • Central Cyanosis

    • Finally, ask the patient to lift their tongue to the roof of the mouth and assess for cyanosis of the tongue. This suggests significant hypoxia - such as due to pulmonary disease or congenital cyanotic heart disease.

Neck

    • Jugular Venous Pressure

    • Visualise the patient’s jugular venous pulsation (JVP) between the sternal and clavicular heads of the sternocleidomastoid. With the bed at 45 degrees, ask the patient to turn their head away from you. Look for the highest level of the jugular venous pulsation, and measure the vertical distance between the sternum and this pulsation. This is elevated if greater than 4cm, which suggests fluid overload, right ventricular failure or pulmonary hypertension.
    • Neck
  • If the jugular venous pulsation is difficult to visualise, assess for hepatojugular reflux. Ask the patient if they have any pain in their abdomen, then gently press over the right upper quadrant for 10-15 seconds - this temporarily increases venous return, making the JVP more pronounced.

    • Carotid Pulses

    • Palpate the carotid pulses one at a time, within the anterior neck medial to the sternocleidomastoid. This is mainly to assess the character of the pulse - a pulses tardis and parvis (late and weak) is suggestive of aortic stenosis, while a waterhammer pulse (strong with sudden collapse) suggests aortic regurgitation.
  • Auscultate the carotid arteries for the presence of a bruit, which suggests carotid artery stenosis. You may also hear the transmitted murmur of aortic stenosis.

Chest Inspection & Palpation

  • Inspect the chest wall both anteriorly and posteriorly for thoracic scars, which may suggest previous chest surgery or trauma. A midline scar (sternotomy) suggests past cardiac surgery (bypass graft or valve replacement), while a scar over the left or right upper chest suggests an implantable device.

    • Apex Beat

    • Next, palpate for the patient’s apex beat. This is the most inferior and lateral point at which the patient’s cardiac impulse is palpable: this is normally in the fifth intercostal space in the midclavicular line (make a show of palpating the ribs down the chest). Feel for displacement, and whether the apex is pressure-loaded or volume-leaded.
    • Chest Inspection & Palpation

    • Abnormal Pulsations

    • Palpate the chest for parasternal heave (over the left side of the sternum) and thrills (palpable murmurs).
    • Chest Inspection & Palpation

Chest Auscultation

  • When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound. You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.
    • Chest Auscultation
    • Chest Auscultation
    • A
      Aortic area - the second intercostal space at the right sternal border
    • P
      Pulmonary area - the second intercostal space at the left sternal border
    • T
      Tricuspid area - the fifth intercostal space at the left sternal border
    • M
      Mitral area - the fifth intercostal space in the midclavicular line
    • Left axilla - the fifth intercostal space in the midaxillary lineListen to each of the areas with the diaphgram of the stethoscope, and also listen to the apex of the heart with the bell - this makes the lower-pitched murmur of mitral stenosis easier to appreciate.

    • Heart Sounds

    • First, listen for the heart sounds.
    • Chest Auscultation
  • The first heart sound (S1) indicates closure of the mitral and tricuspid valves, and is normal heart best over the apex. Listen for presence of S1, and whether it is loud or soft.
  • The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves. Normally on expiration, S2 splits into separately audible A2 and P2 sounds. Note whether the second heart sound is loud or soft.
    • Chest Auscultation
  • The third heart sound (S3) is a pathological finding associated with rapid ventricular filling. This is a gallop rhythm, with an extra heart sound heard just after S2.
    • Chest Auscultation
  • The fourth heart sound (S4) is a pathological finding associated with turbulence during atrial systole. This is also a gallop rhythm, with an extra heart sound heard just before S1, usually best heard during inspiration.

    • Pericardial Rub

    • Next, listen for a pericardial rub. This is a superficial, scratching sound present in mid-systole, mid-diastole and late diastole; the presence of a rub suggests pericarditis due to infection, trauma, uraemia, autoimmunity or malignancy.

    • Listen for Murmurs

    • Next, auscultate the chest for cardiac murmurs. If a murmur is present, palpate the carotid pulse while auscultating to determine whether the murmur is systolic, diastolic (between S2 and S1 of the next cardiac cycle) or continuous. Grade the intensity of the murmur from 1 (incredibly faint) to 6 (audible with the stethoscope off the chest).
  •  
    Read our guide to cardiac murmurs
  • A systolic murmur is present between S1 and S2. An ejection (or mid) systolic murmur is a classical sign of aortic stenosis, while a pansystolic murmur is associated with mitral regurgitation. Click to read more about murmurs that occur during systole.
  • A diastolic murmur is present between S2 and S1. An early diastolic murmur is classically a sign of aortic regurgitation, while a mid-diastolic murmur (usually heard with the bell of the stethoscope) suggests mitral stenosis. Click to read more about diastolic murmurs.
  • Continuous murmurs are uncommon and are associated with rare conditions such as patent ductus arteriosus and AV fistulas.

    • Listen in Inspiration and Expiration

      It is important to listen to cardiac murmurs in both inspiration and expiration. 
    • A murmur that is louder on inspiration suggests right-sided (tricuspid or pulmonary) valvular disease
    • A murmur that is louder on expiration suggests left-sided (aortic or mitral) valve disease.
  • A fourth heart sound is also best heard during inspiration.

    • Left Lateral Position

    • Ask the patient to roll to the left lateral position and listen to the cardiac apex with the bell of the stethoscope. The murmur of mitral stenosis is louder in this position, as is a third heart sound.
    • Chest Auscultation

    • Sitting Forward

    • Ask the patient to sit forward, breath in deeply and then hold their breath in full expiration. This will make the murmurs of aortic and pulmonary regurgitation louder, and will also accentuate a pericardial rub.

    • Dynamic Manoeuvres

      In patients with suspected hypertrophic cardiomyopathy (i.e. patients with a systolic murmur), offer to perform dynamic manoeuvres:
    • Asking the patient to valsalva (breath out hard against a closed mouth and nose) will make the murmur of hypertrophic cardiomyopathy louder, but reducing preload on the heart.
    • Asking the patient to squat increases preload, which makes the murmur of hypertrophic cardiomyopathy softer; then asking the patient to stand up acts as a physiologic bolus which increases preload and makes the murmur louder.

Back

    • Sacral Oedema

    • Palpate the lower back for sacral oedema, as often fluid overloaded patients who are lying down with their legs up will accumulate fluid in this area rather than in their feet.
    • Back

    • Lung Fields

    • Auscultate the lung fields, listening for crepitations and wheeze (signs of left ventricular failure / pulmonary oedema) and reduced air entry (a sign of pleural effusions). Often in the cardio exam it is quicker to auscultate only the lung bases to conserve time. Consider percussing the chest for dullness, to prove suspected pleural effusions.

Abdomen

  • If you are running out of time, skip to the legs at this point as these will provide the highest yield.

    • Inspection

    • Inspect the abdomen for distension and any abnormal movements. A visible abdominal pulsation is a sign of abdominal aortic aneurym, though this sign can also be normal in thin patients.

    • Auscultation

    • Auscultate for abdominal bruits. Listen for aortic bruits, over the upper abdomen in the midline, and renal bruits, over the upper abdomen on either side of the umbilicus. The presence of bruits would suggest arterial stenosis, due to atherosclerosis or other pathology.
    • Abdomen

Legs

    • Palpation

    • Palpate the extremities for temperature, tenderness and pedal oedema.
  • Cool extremities are a sign of poor perfusion; localised hypoperfusion may occur due to arterial disease or compartment syndrome, while more generalised hypoperfusion is a sign of shock. Warm extremities have a wide variety of causes. Significant unilateral warmth suggests cellulitis or a DVT, while milder warmth suggests fluid accumulation due to venous insufficiency or lymphoedema.
  • Next, palpate for pedal oedema. Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release, looking for persistence of the depressed area after the finger is removed. If the oedema is pitting, this suggests fluid overload, right ventricular failure, venous pathology or hypoalbuminaemia; non-pitting oedema suggests lymphoedema.
    • Legs

    • Pulses

    • Palpate the lower limb pulses - dorsalis pedis, posterior tibial and popliteal. Absent pulses are a sign of acute or chronic arterial insufficiency, though patients with shock or severe hypotension may also have absent pulses.
    • Legs

Finishing Up

  • Thank the patient, turn around and present your findings.
  • Ask for an electrocardiogram (ECG), urinalysis, and fundoscopy to complete your assessment.
Last updated on March 29th, 2020
 
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 Barnard S. Thoracic Incisions. Surgery. 2004; 22(5): 105-107. Bergan JJ, Schmid-Schonbein GW, Smith PD, Nicolaides AN, Boisseau MR. Mechanisms of Disease: Chronic Venous Disease. The New England Journal of Medicine. 2006 Aug; 355(5): 488-498. Betul A. Hatipoglu. Cushing’s Syndrome. Journal of Surgical Oncology. 2012 Oct; 106(5): 565-571.
Butler R, Radhakrishnan R. Dementia. Clinical Evidence. 2012; 9.
 Campbell DB. Thoracic Incisions. Operative Techniques in General Surgery. 2008; 10(2): 77-86. Cheng TO. Grading Murmurs Must Always Indicate the Grading System Used. International Journal of Cardiology. 2009 Jun; 135(2): 143-145. Clark A, Cleland JG. Causes and Treatment of Oedema in Patients with Heart Failure. Nature Reviews Cardiology. 2013 Mar; 10: 156-170. Cotter L. History and Examination of the Cardiovascular System. Medicine. 38(7): 344 - 347. Daniel P Judge, Harry C Dietz, Marfan's syndrome, The Lancet, Volume 366, Issue 9501, 3-9 December 2005, Pages 1965-1976 Del Guidice P. Cutaneous Complications of Intravenous Drug Use. The British Journal of Dermatology. 2004;150(1) . Dihingia P, Pegu AK, Chaliha MS, Baruah KD, Kar S, Pramod GR, Kakati S. Takayasu’s Disease–Spectrum of Manifestations A Case Series. Official Journal of Association of Physicians of India, Assam Chapter.:31. Dornhurst AC. Pulsus Paradoxus. Intensive Care Medicine. 1986; 12: 387-388. Drasner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med. 2001; 345: 574–581. Farrior III JB, Silverman ME. A consideration of the differences between a Janeway's lesion and an Osler's node in infectious endocarditis. Chest. 1976 Aug 1;70(2):239-43. Fowler NO. Adolph RJ. Fourth Sound Gallop or Split First Sound?. The American Journal of Cardiology. 1972 Sept; 30: 441-444. Fuller GN, Hargreaves MR, King DM. Scratch Test in Clinical Examination of the Liver. Lancet. 1988; 331(5878): 181. Getzen JH, Dimond EG. Saga of the Fourth Heart Sound. The American Journal of Cardiology. 1968 Nov; 22(5): 608-613. Gillam PM, Deliyannis AA, Mounsey JP. The Left Parasternal Heave. British Heart Journal. 1964; 26: 726. Gray IR. Paradoxical splitting of the second heart sound. British heart journal. 1956 Jan;18(1):21. Grey JE, Enoch S, Harding KG. ABC of Wound Healing: Venous and Arterial Ulcers. British Medical Journal. 2006 Feb; 332: 347-350. Gunson TH, Oliver GF. Osler's nodes and Janeway lesions. Australasian Journal of Dermatology. 2007 Nov;48(4):251-5. Gupta K, Dhawan A, Abel C, Talley N, Attia J. A Re-evaluation of the Scratch Test for Locating the Liver Edge. BMC gastroenterology. 2013; 13: 35.
Haber R, Khoury R, Kechichian E, Tomb R. Splinter hemorrhages of the nails: a systematic review of clinical features and associated conditions. International journal of dermatology. 2016 Dec;55(12):1304-10.
 Hass PL. Differentiation and Diagnosis of Jaundice. AACN Clinical Issues. 1999; 10(4): 433-441. Henkind SJ, Benis AM, Teichholz LE. The Paradox of Pulsus Paradoxus. American Heart Journal/ 1987; 114: 198-203. Holleman DR, Simel DL. Does the Clinical Examination Predict Airflow Limitation?. JAMA. 1995 Jan; 273(4): 313-319. James K, Jonas M. Shock. Medicine. 2009 Jan; 37(1): 6-10. Jansson L, Lavstedt S, Frithiof L, Theobald H. Relationship between oral health and mortality in cardiovascular diseases. Journal of Clinical Periodontology. 2001 Aug; 28(8): 762-768.
Jebb S. Obesity: causes and consequences. Women's Health Medicine. 2004;1:38-41.
 Kalantar J, Talley N. Unexplained weight loss. Current Therapeutics. 1998; 39: 37-43.
Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Grading Heart Murmur Intensity. Arch Pedtr Adolesc Med. 2005. 159(4): 329-334.
 Khare N, Puri V, Venkateshwaran N. Trophic Ulcers - Practical Management Guidelines. Indian Journal of Plastic Surgery. 2012; 45(2): 340-351. Kidd HR. Examination of the Mouth. Canadian Family Physician. 1976 May; 22: 59-62. Kirby B, MacLeod K. Clinical examination of the heart. Medicine. 2006 Apr; 34(4): 123-128. Lear SA, James PT, Ko GT, Kumanyika S. Appropriateness of waist circumference and waist-to-hip ratio cutoffs for different ethnic groups. Eur J Clin Nutr. 2010;64:42-61. Leatham A. Auscultation of the heart. Lancet. 1958; 2: 702-708 757-765. Lee WH, Fisher J. Right Ventricular Diastolic Disorders.Archives of Internal Medicine. 1983 Feb; 143: 332-337. Lembo NJ, Dell’Italia LJ, Crawford MH, O’Rourke RA. Bedside Diagnosis of Systolic Murmurs. The New England Journal of Medicine. 1988; 318(24): 1572-1578. Loeys BL, Dietz HC, Braverman AC, Callewaert BL, De Backer J, Devereux RB, Hilhorst-Hofstee Y, Jondeau G, Faivre L, Milewicz DM, Pyeritz RE. The revised Ghent nosology for the Marfan syndrome. Journal of medical genetics. 2010 Jul 1;47(7):476-85. Lucy Flanders, Robert Tulloh, Cardiac problems in Down syndrome, Paediatrics and Child Health, Volume 21, Issue 1, January 2011, Pages 25-31
Malnick SDH, Knobler H. The medical complications of obesity. QJM : monthly journal of the Association of Physicians. 2006;99:565-579.
Margolies A, Wolferth CC. The opening snap (claquement d'ouverture de la mitrale) in mitral stenosis, its characteristics, mechanism of production and diagnostic importance. American Heart Journal. 1932 Apr 1;7(4):443-70.
 Mathias CJ, Kimber JR. Postural Hypotension: Causes, Clinical Features, Investigation and Management. Annual Review of Medicine. 1999; 50: 317-336. McCullough L, Arora S. Diagnosis and treatment of hypothermia. Am Fam Physician. 2004;70:2325. McLoughlin MJ, Colapinto RF, Hobbs BB. Abdominal Bruits: Clinical and Angiographic Correlation. JAMA. 1975 Jun; 232(12): 1238-1242. McLoughlin MJ, Colapinto RJ, Hobbs BB. Abdominal bruits. Clinical and angiographic correlation. JAMA. 1975 Jun 23;232(12):1238-42. McMullen SM, Ward P. Cyanosis. The American Journal of Medicine. 2013; 126(3): 210-212. Merrigan JM, Hamdan A, Lynm C, Livingston EH. Varicose Veins. JAMA. 2012; 308(24): 2638. Molnar F, Frank CC. Determining the causes of postural hypotension. Canadian Family Physician. 2018 Jan 1;64(1):40-. Morgan T. Turner syndrome: diagnosis and management. American family physician. 2007 Aug 1;76(3). N Assy, G Jacob, G Spira and Y Edoute. Diagnostic approach to patients with cholestatic jaundice. WJG, 1999 June; 5(3):252-262 Nancy J Roizen, David Patterson, Down's syndrome, The Lancet, Volume 361, Issue 9365, 12 April 2003, Pages 1281-1289 O'Rahilly R, The normal cardiac apex and apex beat: A critical review of recent data. American Heart Journal. 1952 Jul; 44(1): 23-34. O’Neill TW, Smith M, Barry M, Graham IM. Diagnostic Value of the Apex Beat. Lancet. 1989 Feb; 334(8661): 499. O’Sullivan OC. On the Nature of High Arched Palate. British Medical Journal. 1934 May; 1(3826): 800. Parker F. Xanthomas and Hyperlipidaemias. Journal of the American Academy of Dermatology. 1985 Jul; 13(1): 1-30. Parmet S. Pericarditis. JAMA. 2003; 289: 1194. Pedersen SD. Metabolic complications of obesity. Best practice & research.Clinical endocrinology & metabolism. 2013;27:179. Perloff JK. Cardiac Auscultation. Disease-a-Month. 1980 Jun; 26(9): 1-47. Petersdorf RG. Hypothermia. Arch Intern Med. 1979;139:399-399. Phillips JH, Burch GE. Selected Clues in Cardiac Auscultation. American Heart Journal. 1962 Jan; 63(1): 1-8. Pickett CA, Jackson JL, Hemann BA, Atwood JA. Carotid Artery Examination, an Important Tool in Patient Evaluation. Southern Medical Journal. 2011 Jul; 104(7): 526-532. Pozo AL, Godfrey EM, Bowles KM. Splenomegaly: Investigation, Diagnosis and Management. Blood Reviews. 2009 May; 23(3): 105-111. Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127:2336-2342. Shively BK. Infective Endocarditis. Current Treatment Options in Cardiovascular Medicine. 2001; 3: 25-35. Smith J. Compartment Syndrome. JAAPA. 2013 Sept; 26(9): 48-49. Sybert VP, McCauley E. Turner's Syndrome. The New England journal of medicine. 2004; 351(12): 1227-38. Taler SJ. Secondary Causes of Hypertension. Primary Care: Clinics in Office Practice. 2008 Aug; 35(3): 489-500. Teasdale G, Jennett B. Assessment of Coma and Impaired Consciousness: a practical scale. Lancet. 1974 July; 304(7872): 81-84. Timmis AJ. The Third Heart Sound. British Medical Journal. 1987. 294: 326-327. Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes M. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2012; 60(14): 1297-1313. Troughton RW, Asher CR, Klein AL. Pericarditis. The Lancet. 2004; 363: 717-727. Tuy T, Peacock WF. Fluid Overload Assessment and Management in Heart Failure Patients. Semin Nephrol. 2012;32:112-120. Uzun G, Mutluoglu M. Dependent Rubor. The New England Journal of Medicine. 2011 Jun; 364(26). Weinberg AD. Hypothermia. Ann Emerg Med. 1993;22:370-377. Woodgate P1, Jardine LA. Neonatal jaundice: phototherapy. BMJ Clin Evid. 2015 May 22;2015. pii: 0319.
Wright SM, Aronne LJ. Causes of obesity. Abdom Imaging. 2012;37:730-732.
 Yasney J. The value of optimising dentition before cardiac surgery. Journal of Cardiothoracic and Vascular Anaesthesia. 2007 Aug; 21(4): 587-591. Yernault JC, Bohadana AB. Chest Percussion. Eur Respir J. 1995; 8: 1756-1760. Zulkowski K, Ratliff CR. Managing Venous and Neuropathic Ulcers. Nursing. 2004 Aug; 24(8): 68.
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