Cardiovascular

-Introduce yourself, ask about pain and explain what you are going to do.

-Position (45 degree) and expose the chest, completely if possible.

-General inspection, looking not only at the patient but around the bed for clues.

-Stand at the end of the bed and make a general inspection for: mitral facies; cyanosis; pallor; jaundice;
dyspnea; sternotomy; Mitral valvotomy; accessory muscles of respiration; syndromes (e.g. Marfan);
deformities.

-Examine the hands and nails for: dilated veins; palmar erythema; clubbing; temperature; colour;
capillary pulsation; Osler's nodes; janeway's lesions; splinter haemorrhage; telangiectases;
arachnodatyly; xanthomas.

-Take the patient's radial and brachial pulses checking rate, rhythm and synchronicity. Check for
radiofemoral delay; chaotic pulse; collapsing character.

-Look over the brachial artery for scars.

-Inspect the eyes from outside, upper and lower conjunctiva.

-Inspect the face for malar rash.

-Inspect the mouth for central cyanosis and dentition.

-Examine the JVP and assess hepatojagular reflux. Is the liver enlarged/pulsatile?

-Palpate the anterior margin of sternomastoid alongside the thyroid cartilage for the carotid pulse.

-Inspect again the chest wall for any scar or deformities.

-Palpate for the apex beat and over the whole precordium for any heaves, thrills or palpable sounds.

-If apex beat abnormal, decide whether it is volume loaded (MR or AR), pressure loaded (heaving in AS
or HTN), lateral and diffuse (failure), or double impulse (HOCM).

-Palpate each valve area in turn with the flat of the fingers for palpable heart sounds and thrills.

- Auscultate each valve area in turn (with synchronization with carotid pulsations) then the carotids.

-Auscultate the apex with the patient turned towards left lateral position by the diaphragm and the bell
moving to the axilla. Auscultate the aortic area with the patient sitting forward.

-Assess the murmurs in both inspiration and expiration based on timing in the cardiac cycle,
configuration, location, radiation, pitch, loudness and duration.

-Lean the patient forwards and examine the back: inspect (scars of coarctation or congenital anomaly
correction surgery?), palpate for sacral edema and auscultate the lung bases for pulmonary edema.

-Palpate the peripheral pulses and examine for peripheral edema.

-Look for evidence of venous harvesting.

-Tell the examiner you would wish to measure the blood pressure, patient's temperature, dip the urine
and perform fundoscopy (to check for endocarditis).

- (THANK the PATIENT and RE-COVER him).