A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; further:
- Inspection (viewing).
- Of the skin and mucous membranes
- Neck vein congestion?
- Edema (praetibial edema?/water retention in the area of the lower leg/before the tibia, ankle; in supine patients: presacral/before the sacrum).
- Generalized peripheral cyanosis [blue coloration of lips and acras (finger/toe extremities, nose, ears)]
- Central cyanosis [bluish discoloration of skin and central mucous membranes, e.g., tongue]
- Auscultation (listening) of the heart, it may be possible to determine:
- Displaced (and widened) cardiac apex bump (palpable bump of the cardiac apex against the anterior chest wall during systole/contraction of the heart; placing the palm of the hand on the left parasternal facilitates finding the cardiac apex bump; this is assessed with two fingers: Location, extent, and strength).
- Auscultation findings: present 3rd heart sound (time: early diastole (relaxation and filling phase of the heart); approx. 0.15 sec. after the 2nd heart sound; due to the impingement of the blood jet on the stiff wall of the (insufficient) ventricle/cardiac chamber)
- Systolic heart murmurs in hypertrophic obstructive cardiomyopathy (HOCM)?Notes:
- Non-obstructive cardiomyopathy (HNCM) usually remains auscultatorily silent.
- A Valsalva maneuver (forced expiration/exhalation against the occluded mouth and nasal opening with simultaneous use of the abdominal press), as a provocation test, must be performed obligatorily when hypertrophic cardiomyopathy (HCM) is suspected, because in a proportion of patients the obstruction exists only under provocation.
- Auscultation of the lungs [in left heart failure:
- Pulmonary edema (fluid in the lungs): tachypnea (> 20 breaths/min); exacerbated breath sounds; inspiratory: bds. moist rales (RGs)/coarse bubbles rales; in severe cases audible without stethoscope (“bubbling of the lungs”); breath sound is attenuated]
- Examination of the abdomen (belly) [in heart failure (cardiac insufficiency): hepatomegaly (liver enlargement)?]
- Auscultation (listening) of the abdomen [vascular or stenotic sounds?, bowel sounds?]
- Percussion (tapping) of the abdomen.
- Meteorism (flatulence): hypersonoric tapping sound.
- Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
- Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size.
- Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, renal bearing knocking pain?).
- Inspection (viewing).
- 6-minute walk test – standardized procedure for objective assessment, determination of severity, and progression of exercise limitation attributable to cardiopulmonary causes (at baseline and during the course of the disease).
- Assessment of consciousness using the Glasgow Coma Score (GCS).
- Health check
Square brackets [ ] indicate possible pathological (pathological) physical findings.Glasgow Coma Scale (GCS) – scale for estimating a disorder of consciousness.
| Criterion | Score | |
| Eye opening | spontaneous | 4 |
| on request | 3 | |
| on pain stimulus | 2 | |
| no reaction | 1 | |
| Verbal communication | conversational, oriented | 5 |
| conversational, disoriented (confused) | 4 | |
| incoherent words | 3 | |
| unintelligible sounds | 2 | |
| no verbal reaction | 1 | |
| Motor response | Follows prompts | 6 |
| Targeted pain defense | 5 | |
| untargeted pain defense | 4 | |
| on pain stimulus flexion synergisms | 3 | |
| on pain stimulus stretching synergisms | 2 | |
| No response to pain stimulus | 1 |
Assessment
- Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
- If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
- With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.