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This audio-recording deals with the general examination of the patient and the specific examination of the precordium. Auscultation of the heart is not the be all and end all of clinical examination of the cardiovascular system (CVS). One should ideally begin with the general physical examination (GPE) of the patient. Often the first thing to notice on examination is the built and stature of the patient. For instance in children with congenital heart disease, there is growth retardation. Rheumatic valvular heart disease in common among women of child-bearing age. In overweight individuals coronary artery disease is common, often associated with diabetes, hypertension and dyslipidemia. In Marfan syndrome we notice a tall, slender patient with long arms and fingers. The general physical examination (GPE) as usual, begins with looking for anemia, cyanosis, jaundice, clubbing and pedal edema. Anemia causes tachycardia, bounding pulses and wide pulse pressure, sometimes associated with high-output heart failure. Cyanosis is seen with congenital heart disease, and chronic lung disease (corpulmonale). A tinge of jaundice is observed due to hepatic congestion in case of right-heart failure. Clubbing of fingers is a feature of left-to-right shunt, bacterial endocarditis as well as suppurative lung disease. Pitting edema around the ankles is an indicator of congestive heart failure. It is associated with hepatomegaly and engorged neck veins. The periorbital region must be examined carefully. In myxedema (hypothyroidism) there is puffiness while in Grave’s disease (hyperthyroidism) there is exophthalmos. In patients with premature coronary artery disease, there may be xanthelasma on the eyelids due to hyperlipidemia or arcus senilis around the cornea. The neck is examined for jugular venous pressure (JVP), the thyroid gland, position of the trachea and signs of insulin resistance. A raised jugular venous pressure (JVP) with normal waves indicates fluid overload or right heart failure. A raised JVP with absent waves indicates superior vena cava (SVC) obstruction. A raised JVP that rises further on inspiration (Kussmaul’s sign) is observed in case of constrictive pericarditis or restrictive cardiomyopathy. The “a” wave is tall in pulmonary valve disease, absent in atrial fibrillation, while cannon “a” waves are seen in atrioventricular dissociation. The “y” descent is rapid in tricuspid regurgitation, absent in cardiac tamponade and deep in case of constrictive pericarditis. The thyroid gland is enlarged in Grave’s disease (hyperthyroidism). There may be a fine tremor, tachycardia, exophthalmos and an audible bruit over the gland. The trachea may be displaced to either side with shift of the mediastinum. It is pulled to the same side by pulmonary collapse or pushed to the other side by pleural effusion. Signs of insulin resistance around the neck are purplish velvety areas in the skin folds (acanthosis nigricans) and skin tags (acrochordon). The pulse is examined for rate, rhythm, volume and character; the radial pulse for rate and rhythm, the brachial pulse for volume and character. A low-volume pulse (pulsus parvus) is observed in aortic stenosis and in any low-output state such as congestive heart failure or cardiac tamponade. A high-volume pulse (collapsing pulse) is observed in aortic regurgitation and in any high-output state such as anemia, thyrotoxicosis or arteriovenous fistula. A pulse with a double-peak (pulsus bisferiens) is a feature of combined aortic stenosis and regurgitation, and of hypertrophic cardiomyopathy. A pulse that falls in volume on inspiration (pulsus paradoxus) is observed in case of constrictive pericarditis and cardiac tamponade. The peripheral pulses are examined for an audible bruit over the carotid arteries and diminished pulsations over the dorsalis pedis arteries. Examination of the precordium begins with inspection. The precordium is inspected for surgical scars, skeletal deformities and visible pulsations. A scar of sternotomy in a child points towards an operated congenital heart disease, while that in an adult indicates prior coronary artery bypass graft (CABG) surgery. Common skeletal deformities are pectus excavatum of the sternum and kyphoscoliosis of the spine. These deformities can potentially displace the apex beat. Pulsations in the suprasternal notch and the epigastrium are visible in aneurysmal dilatation of the ascending and descending aorta respectively. The first and foremost reason for palpation of the precordium is to locate the apex beat and to assess its character. The apex beat is the lowermost and outermost point of the cardiac pulsation. It is normally located in the 5th intercostal space in the midclavicular line. The apex beat is difficult to locate if there is any intervening tissue between the palpating finger and the cardiac impulse. Examples of intervening tissue are fat in obesity, muscle in athletic built, air in pulmonary emphysema and fluid in pericardial effusion. The apex beat is displaced downwards and outwards in case of left ventricular dilatation. It is displaced to the left by pectus excavatum and kyphoscoliosis. Pulmonary disease can also displace the apex beat. Lung collapse pulls the apex beat to the same side while pleural effusion pushes the apex beat to the opposite side. Accordingly, reasons for a right-sided apex beat are mirror-image dextrocardia, a left-sided pleural effusion or a right-sided lung collapse. The apex beat may be localized or diffuse and tapping or heaving in character. It is localized in left ventricular hypertrophy and diffuse in ventricular enlargement. The apex beat is tapping in mitral stenosis and heaving in mitral regurgitation. The heave is sustained in aortic stenosis and ill-sustained in case of mitral regurgitation. The next reason for cardiac palpation is to feel a parasternal heave in case of right ventricular hypertrophy, by placing the edge of the palm to the left of the sternum. A cardiac murmur greater than grade 4/6 in intensity, is palpated as a thrill. The thrill of aortic stenosis and mitral regurgitation radiate towards the neck and axilla respectively. Percussion of the precordium has specific indications. The area of cardiac dullness is enlarged in case of pericardial effusion. In case of left ventricular failure, an area of dullness is percussed over the right lung base, due to the presence of a pleural effusion. When the lower edge of the liver is palpable, careful percussion of the upper edge can differentiate between an enlarged liver from a liver that’s pushed down by emphysema.