Cardiovascular Examination:

• Introduce self, obtain consent and co-operation to examine, confirm ID

of patient.
• Perform hand hygiene, roll up sleeves and remove watch.
• Position the patient appropriately; lying on a bed or sitting up at 45°.
• Expose them to waist if male, but keep female patients covered until
closer inspection e.g. when examining the precordium. Ask patient to
take shoes and socks off
• Explain the procedure to the patient and what you are doing throughout
the examination.
General Inspection:
1. Assess the patients general state.
> Do they appear ill or well?
> Are they in pain? Are there any signs of discomfort?
2. Look for clues e.g. bedside (oxygen, GTN spray, medication, other
bedside equipment)
3. Colour: is the patient pale, cyanosed, flushed?
> are they cold and clammy?
4. Shortness of breath? Any pain or breathing difficulty?
> are they dyspnoeic?
5. Scars on chest wall? E.g. Coronary artery bypass graft (CABG) scar/
Build of patient
> can you hear the click of a prosthetic valve?
> Median sternotomy (CABG, valve replacement, congenital heart disease)
> inspect for any pacemakers/internal cardiac defibrillators (ICD's)
6. Oedema

Hands:
Assess temperature of the hands
Capillary refill time
Inspect skin:
o Tobacco staining/tar staining
o Peripheral cyanosis –congenital heart disease, heart failure
o Tendon xanthomata (Hyperlipidaemia)
o Janeway lesions- red macules on palms (sign of infective
endocarditis)
o Osler's nodes - tender nodules e.g. in finger pulps (signs of
infective endocarditis)
Inspect nails:
 o Clubbing – (congenital heart disease and endocarditis) inspect
with schamwroths window
o Splinter haemorrhages- tender nodules e.g. in finger pulps (sign of
infective endocarditis)
o Nail bed pulsation (Quincke's sign of aortic regurgitation)
o Nail fold infarcts (Vasculitis)

> if Janeway lesions, Osler's nodes and splinter haemorrhages are found
examine the fundi for Roth's spots (retinal infarcts)
> is there arachnodactyly (Marfan's) or polydactyly (ASD)
o Capillary refill test

Radial and Brachial pulses:

Radial:
o Assess the pulse rate, the rhythm of the pulse
o Is there a radio-radial delay? ( Aortic arch aneurysm) Palpate the
pulse on patients wrists, bilaterally and simultaneously.
o Is there a radio-femoral delay?( Coarctation of the aorta) Palpate
ipsilateral pulses simultaneously
o Is there a collapsing pulse? Identify the radial pulse and them
wrap your fingers around the wrist , before elevating the arm
from the elbow. Check for pain in the arm and/or shoulder. Lift
the arm straight up: if there is a collapsing pulse – it will be felt as
a "water hammer" pulsation
Brachial:
o Just medial to tendinous insertion of biceps (waveform character)

Blood pressure:
o Hyper or hypotensive?
o Pulse pressure ; --> Wide = aortic regurgitation, arteriosclerosis
--> Narrow = aortic stenosis, dry

Neck:
Jugular venous pressure:
o Ask patient to turn head to the left 45o and look at the
supraclavicular fossa
o Comment on the height of the JVP and the waveform.
o Raised JVP = Right heart failure
o Press on the abdomen to check the abdomen-jugular reflex.
o Observe for a raise in JVP
o Positive result = rise in 4 or more cm
Carotid pulse:
o Inspect; visible carotid = Corrigan's sign of aortic regurgitation
o Auscultate the carotid arteries using a stethoscope to detect
bruits.
o If no bruits are found then:
o Palpate volume and character on one side then the other.
o Not both simultaneously as this can make patient feel faint.

Face:

• Colour:
> pale
> Flushed
> Central cyanosis

• Features:
> Corneal/senile arcus (hyperlipidemia)
> Xanthelasma (hyperlipidemia)

• Pallor of the conjunctiva --> anaemia

• Malar flush --> mitral stenosis, low cardiac output
• Dental hygiene
• Central cyanosis – hypoxia
• Angular stomatisis- outside of lips
• High arched palate --> marfan's syndrom
• Examine fundi for hypertensive changes
• Are there signs of graves disease? E.g. budging eyes (exophthalmos) or
goitre
• Is the face dysmorphic? E.g. in down's syndrome, Marfan's syndrome,
Turner's, Noonan's, or Williams syndromes?

The Praecordium:

Inspect:
• Scars:
> Midline sternotomy
> Lateral thoracotomy (mitral stenosis valvotomy)
• Chest deformaties
• Pacemakers and subcutaneous ICD
 • Scars on chest wall? E.g. Coronary artery bypass graft (CABG) scar/ Build
of patient
> can you hear the click of a prosthetic valve?
> Midline sternotomy (CABG, valve replacement, congenital heart
disease)
>lateral throacotomy (mitral stenosis valvotomy)
> inspect for any pacemakers/internal cardiac defibrillators (ICD's)

Palpate:
• Apex beat (lowermost lateral pulsation)
> usually the 5th intercostal space in mid clavicular line; measure the
position by counting intercostal spaces. (sternal notch = 2nd intercostal
space)
> undisplaced/displaced?
> Character: impalpable(dextrocardia/COPD), Tapping (palpable S1),
double impulse, sustained/strong
>Tapping-mitral stenosis-especially a palpable 1st heart sound, diffuse-
LV failure, dilated cardiomyopathy, or double impulse.
> Count rate if pulse irregular (Atrial fibrillation)
• Is there dextrocardia?
• Thrusting - caused by by volume overload e.g mitral or aortic
incompetence
• 'Heaves' and 'Thrills'
> place the heel of the hand flat on the chest, to the left then to the right
of the sternum.
> Heave: sustained thrusting usually felt at the left sternal edge (- right
ventricular enlargement)
>heaving is caused by outflow obstruction e.g. aortic stenosis or
systemic hypertension
>feel for left parasternal heave- RV enlargement, e.g. pulmonary
stenosis, cor pulmonale
> Thrill: palpable murmur felt as a vibration beneath your hand -
transmitted murmurs
Auscultate: (palpate carotid pulse simultaneously)
• Apex (mitral area) - fifth intercostal space, midclavicular line
> listen with bell and diaphragm
> Identify 1st and 2nd heart sounds. Are they normal?
> listen for added sounds and murmurs
 > with the diaphragm listen for a pansystolic murmur radiating to the
axilla – mitral regurgitation
• At apex with bell, ask the patient to 'roll over onto your left side and
breathe out and hold it there' ( A rumbling mid-diastolic murmur – mitral
stenosis)
• Lower left sternal edge (tricuspid area (4th intercostal space) and
pulmonary area (2nd intercostal space) left sternal edge)
> left of manubrium in the 2nd intercostal space
> if there is a suspected right sided murmur listen with patients breathe
held in inspiration.
• Right of manubrium in 2nd intercostal space (Aortic valve area), right
sternal edge
> ejection systolic murmur radiating to the carotids --> aortic stenosis
• Auscultate for bruits over the carotids and elsewhere particularly if there
is inequality between pulses or the absence of a pulse. Causes:
atherosclerosis (elderly), vasculitis (young)
• Sit the patient up and listen at the lower left sternal edge with patient
held in expiration ( early diastolic murmur: aortic regurgitation).

To complete the examination:

Lungs:
o Auscultate the lung bases for inspiratory coarse crackles,
pulmonary oedema secondary to left ventricular failure.
o Examine the bases for creps and pleural effusions, indicative of
cardiac failure.
Oedema:
o Palpate and apply pressure for 15seconds to the sacrum (sacral
oedema), legs (pedal oedema), torso and ankles for pitting
oedema (indicative of right ventricular failure) and feel for any
indentations
o Ankles can be examines at the foot of the bed as it is a good early
clue that there may be further pathology to be found.
Abdomen:
o Examine the abdomen for a pulsatile liver
o Hepatomegaly and ascites in right-sided heart failure
o Pulsatile hepatomegaly with tricuspid regurgitation
o Splenomegaly with infective endocarditis
o aortic aneurysm
Fundoscopy:
o Roth spots (infective endocarditis)
Other checks:
o Check peripheral pulses, observation chart for temperature and
02 sats
 o ECG
o Blood pressure

Thank patient, summarise findings and wash your hands.

Blood Pressure:
o Systolic Blood Pressure: the pressure at which the pulse is first
heard as on cuff deflation (Korotkoff sounds)
o Diastolic Blood Pressure: when the heart sounds disappear or
become muffled (e.g. in the young)
o Pulse pressure: the difference between systolic and diastolic
pressures.
> narrow in aortic stenosis and hypovolaemia
> wide in aortic regurgitation, arteriosclerosis and septic shock
o Shock may occur if systolic <90mmHg
o Postural hypotension: a drop in systolic >20mmHg or diastolic
>10mmHg on standing for 3-5min
o Need approx 3 readings to diagnose hypo or hypertension and
need to take into account; pain, the white coat effect and the
equipment
o Getting the right cuff size is vital; optimal cuff is 40% of the arm
circumference

Other tips:
o The hand can be used as a manometer to estimate JVP /CVP if you
cannot see the neck properly (eg. Central line in situ.)
o Hold the hand palm down below rh e level of the heart until the
veins dilate (patient must be warm). Then lift slowly, keeping the
arm horizontal, and the veins should empty as the hand is raised.
Empty veins below the veins of the heart suggests a low CVP, if
they remain full it suggests a normal/high CVP