THE CARDIOVASCULAR EXAM

A)PROCEDURE
1.)Wash hands
2.)Introduce yourself to patient and Gain consent
3.)Recline patient at 45°
4.) NOTE: Be at the right side of the patient’s bed before you begin the exam
5.)Look at the patient’s surroundings for objects or equipment on or around the patient that
may provide useful insights into their medical history and current clinical status:

 Medical equipment: note any oxygen delivery devices, ECG leads, medications (e.g.
glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous
access.
 Mobility aids: items such as wheelchairs and walking aids give an indication of the
patient’s current mobility status.
 Pillows: patients with congestive heart failure typically suffer from orthopnoea,
preventing them from being able to lie flat. As a result, they often use multiple pillows
to prop themselves up.
 Vital signs: charts on which vital signs are recorded will give an indication of the
patient’s current clinical status and how their physiological parameters have changed
over time.
 Fluid balance: fluid balance charts will give an indication of the patient’s current fluid
status which may be relevant if a patient appears fluid overloaded or dehydrated.
 Prescriptions: prescribing charts or personal prescriptions can provide useful information
about the patient’s recent medications.

6.)From the end of the bed observe the patient’s general appearance

 Are they comfortable?

 Do they look unwell?
 Are they in distress? E.g. in pain, in respiratory distress
 Are they obviously cyanosed?
 Are they obviously pale?
 Do they have obvious scars?
 Are they edematous?
 Malar flush/ mitral facies?

 Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis.
7.)Inspect the hands for clinical signs relevant to the cardiovascular system:

 Capillary refill time

 Finger clubbing
 Peripheral cyanosis
 Splinter hemorrhages
 Pallor
 Nicotine staining
 Xanthomata
 Temperature
 Arachnodactyly
 Janeway lesions
 Osler’s nodes

a)Capillary refill time (CRT)

Capillary refill time (CRT) is defined as the time taken for color to return to an
external capillary bed after pressure is applied to cause blanching.
Technique:

 Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and
then release.
 The most reliable and applicable site for CRT testing is the finger pulp (not at the
fingernail).
 In healthy individuals, the initial pallor of the area you compressed should return to its
normal colour in less than two seconds.
 A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g.
hypovolaemia, congestive heart failure)

b) Finger clubbing
Finger clubbing refers to the bulbous uniform swelling of the soft tissue of the terminal phalanx
of a digit with subsequent loss of the normal angle between the nail and the nail bed.
Lovibond’s angle refers to the angulation between the nail plate and the skin below the nail (the
nail base), when viewed laterally. Normally it is less than 180°. When clubbing is present, the
angle is at least 180°, or more.
Technique:

 Ask the patient to place the nails of their index fingers back to back.
 In a healthy individual, you should be able to observe a small diamond-shaped
window (known as Schamroth’s window)
 When finger clubbing develops, this window is lost.
Cardiac Causes of Finger clubbing:

 Congenital cyanotic heart disease

 Infective endocarditis
 Atrial myxoma (very rare).
Causes of Finger clubbing (General):
C
 Congenital cyanotic heart disease
 Cystic fibrosis
 Celiac disease
L
 Lung cancer- bronchogenic carcinoma
 Lung abscess
U
 Ulcerative colitis
B
 Bronchiectasis
 Benign mesothelioma
 Biliary cirrhosis
I
 Infective endocarditis
 Idiopathic pulmonary fibrosis
 Inflammatory bowel disease
 Idiopathic
N
 Neurogenic tumors
F
 Familial
A
 Atrial myxoma
 Asbestosis
c)Peripheral cyanosis
Cyanosis is a blue discoloration of the skin and mucous membranes caused by increased
concentration of reduced haemoglobin in the superficial blood vessels.
Peripheral cyanosis may result when cutaneous vasoconstriction slows the blood flow and
increases oxygen extraction in the skin and the lips.
Technique:
 In dark-skinned people, cyanosis may be easier to see in the mucous membranes (lips, gums,
around the eyes) and nails.
Causes Of Peripheral Cyanosis:
 Hypothermia/ cold exposure
 Arterial obstruction e.g. PAD, Raynaud’s phenomenon
 Congestive Heart Failure
 All causes of central cyanosis

d)Splinter haemorrhages
Splinter haemorrhages: a longitudinal, red-brown lines of minute foci of capillary haemorrhage
between the nail plate and nail bed that look like a wood splinter.
Causes Of Splinter Hemorrhages:
 T-trauma
 R-Rheumatoid arthritis
 I-Infective endocarditis
 P-psoriatic nails
 S-SLE, scleroderma
 A-antiphospholipid syndrome

e)Pallor

Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic
disease. Anaemia may exacerbate angina and heart failure.) or poor perfusion (e.g. congestive
cardiac failure).

It should be noted that a healthy individual may have a pale complexion that mimics pallor,
however, pathological causes should be ruled out.

f)Nicotine staining

Nicotine staining: Dark yellow stains on the fingertips caused by smoking, a significant risk
factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
g)Xanthomata

They are yellow nodules or plaques characterized by accumulation of lipid-laden macrophages

that are often noted on the palm, tendons of the wrist and elbow.

Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia),

another important risk factor for cardiovascular disease (e.g. coronary artery disease,
hypertension).

h)Temperature

Technique:
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
 In healthy individuals, the hands should be symmetrically warm, suggesting adequate
perfusion.
 Cool hands (coldness of the extremities) may suggest poor peripheral perfusion (e.g. due to
reduced cardiac output in congestive cardiac failure, acute coronary syndrome).
 Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.

i)Arachnodactyly
Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in
comparison to the palm of the hand and arch of the foot.
Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve
prolapse and aortic dissection.

j)Janeway lesions
Janeway lesions are irregular, non-tender, erythematous, or hemorrhagic macules or papules
commonly found on the thenar and hypothenar eminences of the palm and soles.
Janeway lesions are typically associated with infective endocarditis.

k)Osler nodes
Osler nodes are tender, purple-pink nodules with a pale center and an average diameter of 1 to
1.5 mm due to dermal infarcts from septic cardiac vegetations.
They are generally found on the distal fingers and toes, though they can also present on the
lateral digits, hypothenar, and thenar muscles.
They are typically associated with infective endocarditis.
8.)Examine the radial pulse(s) for:
 Rate
 Rhythm
 Character
 Symmetry

a)Rate
Normal Range
According to the American Heart Association (AHA), the average resting heart rate is between
60 and 100 beats per minute.
Technique:
 By convention, both rate and rhythm are assessed by palpating the right radial pulse.
 Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your
index and middle fingers aligned longitudinally over the course of the artery.
 Rate, expressed in beats per minute (bpm), is measured by counting the number of beats in a
timed period of 15 seconds and multiplying by 4.
 For irregular rhythms, you should measure the pulse for a full 60 seconds to improve
accuracy.
Causes of Tachycardia
A pulse of >100 bpm is known as tachycardia
Causes of Bradycardia
A pulse <60 bpm is known as bradycardia
b)Rhythm
Normal sinus rhythm is regularly regular
Causes Of Irregularly Irregular Pulse
 Atrial fibrillation
 Atrial flutter with variable heart block
 Atrial or ventricular ectopics
Causes Of Regularly Irregular Pulse
 Sinus arrhythmia
 Ventricular bigeminus/ trigeminus
 Second degree heart block
 Atrial tachyarrythmias with a fixed AV block

c)Character
Pulse Strength is recorded using a four-point scale:
 3+ Full, bounding
 2+ Normal/strong
 1+ Weak, diminished, thready
 0 Absent/non-palpable
Bounding Pulse
Defined as a throbbing, excessively strong pulse
Causes Of A Bounding Pulse
 Aortic regurgitation
 Patent Ductus Arteriosus
 High output states
a) Thyrotoxicosis
b) Anemia
c) Sepsis
d) Exercise
e) Fever
f) Pregnancy
g) Beriberi
h) AV fistula

 Essential (Primary) hypertension

 Paget disease
 Liver cirrhosis
 Cor pulmonale

Weak Pulse
Defined as a softer pulsation than normally felt
Causes
 Shock
 Cardiac arrest

Thready Pulse
Defined as a scarcely perceptible and commonly rapid pulse that feels like a fine mobile thread
under a palpating finger.
Causes
 Cardiogenic shock

Collapsing Pulse
Collapsing pulse, also known as Watson's water hammer pulse, is the medical sign which
describes a pulse that is bounding and forceful, rapidly increasing and subsequently collapsing,
as if it were the sound of a water hammer that was causing the pulse.
Technique:
To assess for a collapsing pulse:
1. Ask the patient if they have any pain in their right shoulder, as you will need to move it
briskly as part of the assessment for a collapsing pulse (if they do, this assessment should
be avoided).
2. Palpate the radial pulse with your right hand wrapped around the patient’s wrist.
3. Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand,
whilst also supporting the patient’s elbow.
4. Raise the patient’s arm above their head briskly.
5. Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you
should be able to feel a tapping impulse through the muscle bulk of the arm. This is
caused by the sudden retraction of the column of blood within the arm during diastole.
Causes of a collapsing pulse
 Normal physiological states (e.g. fever, pregnancy)
 Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
 High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)

d)Symmetry
Radio-radial delay
Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm,
resulting in the pulses occurring at different times.
To assess for radio-radial delay:
 Palpate both radial pulses simultaneously.
 In healthy individuals, the pulses should occur at the same time.
 If the radial pulses are out of sync, this would be described as radio-radial delay.
Causes Of Radio-Radial Delay
1. Coarctation of the aorta
2. Subclavian artery stenosis (e.g. compression by a cervical rib)
3. Emboli
4. Aortic aneurysm and occlusion
5. Aortic dissection
6. Takayasu disease
 7. Pressure over axillary artery by tumor, lymph nodes
8. Supraclavicular aortic stenosis
9. Normal anatomic variants
Radio-femoral Delay
How to elicit radio-femoral delay?
To detect the radio-femoral delay you have to palpate the radial (using left hand) and femoral
artery (using right hand) simultaneously. Normally the time taken for the pulse wave to reach the
radial artery after the cardiac systole is 80 milliseconds and for the femoral artery it is
75milleseconds.If the femoral pulse is delayed compared to radial pulse it is called as radio-
femoral delay.
Causes of radio-femoral delay
 Coarctation of aorta
 Atherosclerosis of aorta.
 Thrombosis or embolism of aorta
 Aortoarteritis.

9.)Palpate the brachial pulse

Brachial pulse
Palpate the brachial pulse in their right arm, assessing volume and character:
1. Support the patient’s right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially flexed and
their forearm is externally rotated.
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial
epicondyle of the humerus. Deeper palpation is required (compared to radial pulse
palpation) due to the location of the brachial artery.
Types of pulse character
 Normal
 Slow-rising (associated with aortic stenosis)
 Bounding (associated with aortic regurgitation as well as CO2 retention)
 Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
10.)Measure the BP

Blood pressure abnormalities

Blood pressure abnormalities may include:
 Hypertension: Hypertension is defined as persistently elevated, systolic and/or diastolic
blood pressure (BP) of 140/90 mmHg or more in subjects aged 18 years and above. The
definition also applies to those individuals who are already taking antihypertensive
medications even if their current blood pressure is less than 140/90mmHg.
 Hypotension: blood pressure of less than 90/60 mmHg.
 Narrow pulse pressure: less than 25 mmHg of difference between the systolic and
diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and
cardiac tamponade (compression of the heart by an accumulation of fluid in the
pericardial sac).
 Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic
blood pressure. Causes include aortic regurgitation and aortic dissection.
 Difference between arms: more than 20 mmHg difference in blood pressure between
each arm is abnormal and may suggest aortic dissection.

Definition and classification of hypertension

Category Systolic Diastolic
Optimal < 120 And < 80
Normal 120-129 And/or 80-84
High normal 130-139 And/or 85-89
Grade 1 140-159 And/or 90-99
hypertension
Grade 2 160-179 And/or 100-109
hypertension
Grade 3 >/equal to 180 And/or >/equal to 110
hypertension
Isolated systolic >/equal to 140 and < 90
hypertension
Technique
 Allow patient to sit for 3–5 minutes before commencing measurement
 The SBP should be first estimated by palpation to avoid missing the auscultatory gap
 Take two readings 1–2 minutes apart. If consecutive readings differ by > 5 mm, take
additional readings
 At initial consultation measure BP in both arms, and if discrepant use the higher arm for
future estimations
 The patient should be seated, back supported, arm bared and arm supported at heart level
 Patients should not have smoked, ingested caffeine-containing beverages or food in
previous 30 min
 An appropriate size cuff should be used: a standard cuff (12 cm) for a normal arm and a
larger cuff (15 cm) for an arm with a mid-upper circumference > 33 cm (the bladder
within the cuff should encircle 80% of the arm)
 Measure BP after 1 and 3 minutes of standing at first consultation in the elderly, diabetics
and in patients where orthostatic hypotension is common
 When adopting the auscultatory measurement use Korotkoff I (appearance) and V
(Disappearance) to identify SBP and DBP respectively
 Take repeated measurements in patients with atrial fibrillation and other arthythmias to
improve accuracy
Choice of cuff size in children
 Newborns and premature infants: 4 × 8 cm
 Infants: 6 × 12 cm
 Older children: 9 × 18 cm

Causes of hypertension
Hypertension is broadly classified into 2 groups:
1. Primary or Essential hypertension:
The cause is unknown, constitutes about 95% of cases in adults. Risk factors include:
• Age above 45 (60 years in women)
• Race (more in blacks)
• Family history
• Overweight/central obesity
• Physical inactivity
• Tobacco use
• High dietary salt
• Low dietary potassium
• Low vitamin D
• Stress
• Chronic/heavy alcohol use
2. Secondary hypertension:
Refers to cases where the cause of hypertension can be identified and sometimes treated, around
5% of the cases. Causes include:
Cardiovascular
 Polyarteritis nodosa
 Coarctation of the aorta
 Increased intravascular volume
 Increased cardiac output
 Rigidity of the aorta
Renal
 Renal artery stenosis
 Renal vasculitis
 Renin-producing tumors
 Polycystic disease
 Acute glomerulonephritis
 Chronic renal disease
Endocrine
 Adrenocortical hyperfunction (Cushing syndrome, primary aldosteronism,
congenital adrenal hyperplasia, licorice ingestion)
 Exogenous hormones (glucocorticoids, estrogen [including pregnancy-
induced and oral contraceptives], sympathomimetics and tyramine-
containing foods, monoamine oxidase inhibitors)
 Pheochromocytoma
 Acromegaly
 Hypothyroidism (myxedema)
 Hyperthyroidism (thyrotoxicosis)
 Pregnancy-induced (pre-eclampsia)
Neurologic
 Psychogenic
 Increased intracranial pressure
 Sleep apnea
 Acute stress, including surgery

Causes of hypotension
11.)Thyroid palpation
Relevance:
High levels of circulating T3 significantly increases metabolism resulting in weight loss and
potentiates the effects of catecholamines such as adrenaline resulting in excessive sympathetic
output (e.g. tachycardia).
Palpate each of the thyroid’s lobes and the isthmus:
1. Stand behind the patient and ask them to tilt their chin slightly downwards to relax the muscles
of the neck to aid palpation of the thyroid gland.
2. Place the three middle fingers of each hand along the midline of the neck below the chin.
3. Locate the upper edge of the thyroid cartilage (“Adam’s apple”) with your fingers.
4. Move your fingers inferiorly until you reach the cricoid cartilage. The first two rings of the
trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area.
5. Palpate the thyroid isthmus using the pads of your fingers.
6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus.
7. Ask the patient to swallow some water, whilst you feel for the symmetrical elevation of the
thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass).
8. Ask the patient to protrude their tongue (if a mass represents a thyroglossal cyst, you will feel
it rise during tongue protrusion).

12.)Assess the height and waveform of the Jugular venous pulse

Jugular venous pressure (JVP)

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is
possible because the internal jugular vein (IJV) connects to the right atrium without any
intervening valves, resulting in a continuous column of blood. The presence of this continuous
column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised
right atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is,
however, sometimes visible due to transmission through the sternocleidomastoid muscle)
Technique:
1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear
lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above
the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a
double waveform pulsation, which helps to differentiate it from the pulsation of the external
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of
the pulsation point of the IJV (in healthy individuals, this should be no greater than 4 cm).

Causes of elevated jugular venous pressure

■ Congestive heart failure
■ Cor pulmonale
■ Superior vena cava obstruction
■ Pulmonary embolism
■ Right ventricular infarction
■ Tricuspid valve disease
■ Tamponade
■ Constrictive pericarditis
■ Hypertrophic/restrictive cardiomyopathy
■ Iatrogenic fluid overload, particularly in surgical and renal patients

13.)Examine the carotid pulse character and volume

Carotid Pulse Palpation:
1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex
bradycardia when palpating the carotid artery (potentially causing a syncopal episode).
2. Gently place your fingers between the larynx and the anterior border of the
sternocleidomastoid muscle to locate the carotid pulse.
3. Assess the character (e.g. slow-rising, thready) and volume of the pulse (Corrigan’s sign?).
Corrigan’s pulse or sign
The Corrigan’s pulse is a bounding carotid pulse, characterized by a rapid systolic rise and a
rapid diastolic collapse. To detect the Corrigan’s sign, inspect the base of the patient’s neck, right
where the carotids are. It is usually found in patients with aortic regurgitation, a condition caused
by a leaky aortic valve.
Note:
 Watson’s water hammer pulse: The water hammer pulse is a bounding pulse with rapid
systolic rising and diastolic collapse that can be appreciated at either the radial, ulnar or
brachial artery. It is accentuated by slightly lifting up the patient’s arm.

14.)Inspect the face, eyes and mucous membranes for the following:

Eyes
Inspect the eyes for signs relevant to the cardiovascular system
 Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull
down their lower eyelid to allow you to inspect the conjunctiva.
 Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea,
typically occurring in patients over the age of 60. In older patients, the condition is
considered benign, however, its presence in patients under the age of 50 suggests
underlying hypercholesterolaemia.
 Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with
hypercholesterolaemia.

Mouth
Inspect the mouth for signs relevant to the cardiovascular system
 Central cyanosis: bluish discolouration of the lips and/or the tongue associated with
hypoxaemia. Cardiac causes include pulmonary oedema (which prevents adequate
oxygenation of the blood) and congenital heart disease. Congenital defects associated
with central cyanosis include those in which desaturated venous blood bypasses the lungs
by (‘reversed’) shunting through septal defects or a patent ductus arteriosus (e.g.
Eisenmenger’s syndrome, Fallot’s tetralogy).
 Angular stomatitis: a common inflammatory condition affecting the corners of the
mouth causing red, swollen patches. It has a wide range of causes including iron
deficiency.
 High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic
valve prolapse and aortic dissection.
 Dental hygiene: poor dental hygiene is a risk factor for infective endocarditis.
Causes Of Central Cyanosis (General)
(With central cyanosis, there is reduced arterial oxygen saturation caused by cardiac or
pulmonary disease. It affects not only the skin and the lips but also the mucous membranes
of the mouth.)
1. Alveolar hypoventilation
a)CNS depression
 Asphyxia
 Seizures
 IVH
 Meningitis/encephalitis
b)Neuromuscular disease
 GBS
 Myasthenia gravis
 Phrenic nerve palsy
c) Chest wall deformities
d)Airway obstruction
2. V/Q mismatch
a)Airway disease
 Pneumonia
 COPD
 Asthma
 PE
b)Extrinsic compression of lung

3. Diffusion impairment
a)Pulmonary edema
b)Pulmonary fibrosis
4. Right to left shunting at the intracardiac, great vessel or intrapulmonary levels
a) TOF
b) Tricuspid atresia
c) Transposition of great vessels
d) Truncus arteriosus
e) Total anomalous pulmonary venous return
 f) Critical pulmonary stenosis
5. Severe CCF
6. Hemoglobinopathy
a) Methemoglobinemia
b) Sulphaemoglobinemia
c) HbM Boston
7.Others
a) High altitude
b) OSA

15.)Inspect the chest for scars and pulsations

Closely inspect the anterior chest

Look for clinical signs that may provide clues as to the patient’s past medical/surgical history:
 Scars suggestive of previous thoracic surgery: see the thoracic scars section below.
 Pectus excavatum: a caved-in or sunken appearance of the chest.
 Pectus carinatum: protrusion of the sternum and ribs.
 Visible pulsations: a forceful apex beat may be visible secondary to underlying
ventricular hypertrophy.
Thoracic scars
 Median sternotomy scar: located in the midline of the thorax. This surgical approach is
used for cardiac valve replacement and coronary artery bypass grafts (CABG).
 Anterolateral thoracotomy scar: located between the lateral border of the sternum and the
mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for
minimally invasive cardiac valve surgery.
 Infraclavicular scar: located in the infraclavicular region (on either side). This surgical
approach is used for pacemaker insertion.
 Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous
implantable cardioverter-defibrillator (ICD).
16.)Palpate the chest to assess the location of the apex beat

Apex beat
Definition
The apex beat is defined as the lowest and most lateral point at which the cardiac impulse can be
palpated.
Technique and Findings:
 Palpate the apex beat with your fingers placed horizontally across the chest.
 In healthy individuals, it is typically located in the 5th intercostal space in
the midclavicular line. Ask the patient to lift their breast to allow palpation of the
appropriate area if relevant.
 Inferior or lateral displacement from its normal location in the fifth intercostal space in
the mid-clavicular line usually indicates cardiac enlargement.

17.)Palpate the praecordium for heaves and thrills

a)Heaves
Definition
 A parasternal heave is a precordial impulse that can be palpated.
Technique and Findings:
 Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for
heaves.
 If heaves are present you should feel the heel of your hand being lifted with each systole.
 Parasternal heaves are typically associated with right ventricular hypertrophy.

b)Thrills
Definition
 A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a
thrill is a palpable murmur).
 Present particularly in aortic stenosis, ventricular septal defect and patent ductus
arteriosus.
Technique:
 You should assess for a thrill across each of the heart valves in turn (see valve locations
below).
 To do this place your hand horizontally across the chest wall, with the flats of your
fingers and palm over the valve to be assessed.
Valve locations
 Mitral valve: 5th intercostal space in the midclavicular line.
 Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
 Pulmonary valve: 2nd intercostal space at the left sternal edge.
 Aortic valve: 2nd intercostal space at the right sternal edge.

18.)Auscultate the heart

Auscultation
Auscultate the four heart valves
A systematic routine will ensure you remember all the steps whilst giving you several chances to
listen to each valve area. Your routine should avoid excess repetition whilst each step should
‘build’ upon the information gathered by the previous steps. Ask the patient to lift their breast to
allow auscultation of the appropriate area if relevant.
NOTE: Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope:
 Mitral valve: 5th intercostal space in the midclavicular line.
 Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
 Pulmonary valve: 2nd intercostal space at the left sternal edge.
 Aortic valve: 2nd intercostal space at the right sternal edge.

Routine for auscultation of the heart

■ Auscultate at apex with diaphragm
■ Reposition patient on left side – ‘Please turn onto your left side’
■ Listen with diaphragm (mitral regurgitation) and then bell (mitral stenosis)
■ Return patient to original position, reclining at 45°
■ Auscultate with diaphragm at lower left sternal edge (tricuspid regurgitation, tricuspid stenosis,
ventricular septal defect)
■ Auscultate with diaphragm at upper left sternal edge (pulmonary stenosis, pulmonary
regurgitation, patent ductus arteriosus)
■ Auscultate with diaphragm at upper right sternal edge (aortic stenosis, hypertrophic
cardiomyopathy)
■ Sit patient forward. Auscultate with diaphragm at lower left sternal edge in held expiration
(aortic regurgitation) – ‘breathe in … breathe out … stop’
■ Auscultate over the carotid arteries (radiation of murmur of aortic stenosis, carotid artery
bruits)

First sound (S1)

 This corresponds to mitral and tricuspid valve closure at the onset of systole.
 It is accentuated in mitral stenosis because prolonged diastolic filling through the
narrowed valve ensures that the thickened leaflets are widely separated at the onset of
systole. Thus valve closure generates unusually vigorous vibrations.
Second sound (S2)
 The second sound corresponds to aortic and pulmonary valve closure following
ventricular ejection.
 S2 is single during expiration.
 Inspiration, however, causes physiological splitting into aortic followed by pulmonary
components because increased venous return to the right side of the heart delays
pulmonary valve closure.
Third and fourth sounds (S3, S4)
 The third and fourth are low-frequency sounds that occur early and late in diastole,
respectively.
 When present, they give a characteristic ‘gallop’ to the cardiac rhythm.
 Both sounds are best heard with the bell of the stethoscope at the cardiac apex.
 Rapid filling occurs early in diastole (S3) following atrioventricular valve opening and
again late in diastole (S4) due to atrial contraction.
S3 Indications
 S3 is physiological in children and young adults but usually disappears after the age of
40. It also occurs in high-output states caused by anaemia, fever, pregnancy and
thyrotoxicosis.
  After the age of 40, S3 is nearly always pathological, usually indicating left ventricular
failure or, less commonly, mitral regurgitation or constrictive pericarditis.
S4 Indications
 In the elderly, S4 is sometimes physiological.
 More commonly, however, it is pathological, and occurs when vigorous atrial contraction
late in diastole is required to augment filling of a hypertrophied, non-compliant ventricle
(e.g. hypertension, aortic stenosis, hypertrophic cardiomyopathy).
Carotid Bruit
A carotid bruit is a vascular sound usually heard with a stethoscope over the carotid artery
because of turbulent, non-laminar blood flow through a stenotic area. A carotid bruit may point
to an underlying arterial occlusive pathology that can lead to stroke.

19.)Auscultate the lungs

20.)Examine the ankles and sacrum for oedema

Sacral oedema
Inspect and palpate the sacrum for evidence of pitting oedema.
Legs
Inspect and palpate the patient’s ankles for evidence of pitting pedal oedema (associated with
right ventricular failure).

21.)Examine the peripheral pulses

22.)To complete the examination…
 Explain to the patient that the examination is now finished.
 Thank the patient for their time.
 Dispose of PPE appropriately and wash your hands.
 Summarise your findings.