Examination of Chest and Abdominal

As aIready mentioned earlier, any overt deformity of the chest, for example kyphosis,scoliosis, pectus exacavatum and pectus carcinatu~n are to be noted as any one these lnay displace the apex beat producing apparent cardiomegaly. Even pectus excavatum can cause functional systolic murmur at lefi sternal border due to pressure from without.

A large descending thoracic aneurysm can produce a thrusting pulsation in lefi. sternal border called Thoracic jerk.Percussion of 2nd intercostals space is very imporiant as obIiteration of resonance always indicate enlargement of large arteries either pulmonary, aorta or sometimes both. An aneurysm of ascending can produce pulsation in right 1st and 2nd interspace.

Excessive pulsation of intercostal arteries in back can be seen and felt especially on stooping forward while standing in case of severe coarctation of Aorta with large collateral vessels.Examinatio~l of Abdomen

The contour of abdomen is to be recorded. Normally tlie abdomen is scaphoid in sharp in a young adult. In case of fullness and bulge presence of ascites is to be ruled by pel*ci~ssion (shifting dullness). Any organomegaly is to be noted, especially for enlargement of liver and spleen. A soft mildly enlarged liver is better demonstrated by light percussion as it may be missed during palpation. Unless the spleen enlarges more than double its size spleenic tip may not be palpable. Hence, in case of suspected enlargement obliteration of spleenic resonance beyond mid axillary line is expected.Kidneys are better palpated by applying pressure by one hand at renal angle and palpating kidney by other hand on nnteriority abdominal wall. Between both hands an enlarged kidney or a renal mass can be felt well and c?n pl~shed backward and forward showing its ballotability. The detection of an enlarged kidney in case of hypertension can be important and poycystic disease of kidney must be ruled out.

In case of aneurysnl a pulsatile mass in the midline of abdomen can be often palpated.When two fingers are placed by tlie side of st~ch Inass a systolic expansile movement is well demonstrated.In elderly patient a saprapubic nlass d ~ I1 r on percussion is caused by enlarged and overdistended bladde~-due to cnlarged prostrate or bladder neck obstruction.Pullnonary hypertension can be secondary to ~msuspected cirrhosis of liver.

Relevant other Examination

Examination ofteelll for any infection is a 111ust especially in valvular heart disease as this can be a potent source of infection.Thyroid gland deserves special mention as occult toxicity may present as recurrent palpitation and/or supracventricular tachycardia. One of tlie remote causes of persistent congestive 1iear-t failure nlay be occi~lt tliyrotoxicosis.

Examination of lower limb for evidence of venous tliro~~~bosis for suspected pullnonay embolis~n or chronic pulmonary hypertension slio~~ld not be overlooked.

Peripheral signs of infective endoca~riitis like Oslar nodes, splinter Iiaemorrhage to be loolced for.

Erythema nodosum over tlie tibia1 shin will point to active rheumatic fever. In arthralgia tlie joint movement may be painfill loi~t will lack tlie sign of inflammation,like rise of temperature and redness. Rlieu~natic nodules are fixed to fascia and cannot be moved underneath the skin and is usually found over subcutaneous bony parts like occiput, subcutaneous radial, bone, libial shin, scapular border and around wrist and knee joints.