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Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose and sit patient at 45⁰

General inspection

  • Stand at the foot of the patient’s bed and look at the patient, and then around the bed
  • Do they look well or unwell?
  • Consider if they are comfortable, alert, breathless, pallored, or cyanosed
  • Not any obvious scars on precordium, pacemaker/devices, audible metallic heart valve sound
  • It is also worth considering their age (gives clues to pathology)
  • See if there are any syndromic features
    • Marfan syndrome is associated with AR/MR/mitral prolapse
    • Turner syndrome is associated with AS
    • Down’s syndrome is associated with congenital heart disease
  • Around the bed: oxygen, medication, IV infusions

Hands

  • Check perfusion
    • Look for peripheral cyanosis
    • Feel the patient’s hand temperature
    • Check their capillary refill by pressing for 5 seconds then releasing the pressure and observe how long it takes for perfusion to return (>2 seconds is classed as hypoperfusion)
  • Nails
    • Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test
    • Clubbing may be seen in cyanotic congenital heart disease, IE)
    • Look for splinter haemorrhages (small capillary bleeds under the nailbed – seen in infective endocarditis)
    • Quincke’s sign is visible capillary pulsations under the nailbed, caused by AR
  • Dorsum: extensor tendon xanthomata (irregular nodules overlying tendons; caused by hyperlipidaemia)
  • Palms: look for Osler’s nodes (painful purple papules on pulps; caused by IE), and Janeway lesions (erythematous macules on palms; caused by IE)

Arms

  • Inspect for bruising (may be seen in patients on anticoagulation, which may be required for AF or metallic heart valve replacements)
  • Radial pulse:
    • Calculate the heart rate by timing for 30 seconds and multiplying by two (tachycardia >100, bradycardia <60)
    • Note the rhythm (irregularly irregular = AF/ectopics/flutter with variable block; regularly irregular = 2nd degree heart block)
    • Examine for radio-radial delay by feeling both radial pulses and determining if they are synchronous or there is a delay (radio-radial delay may be caused by aortic dissection/aneurysm or proximal coarctation)
    • Offer to test for radio-femoral delay (aortic coarctation)
  • Collapsing pulse: first ensure the patient has no shoulder pain. Hold their extended elbow with your left hand and wrap your right hand around their wrist. Start with their arm downwards and release the pressure from around their wrist until you can only just feel their radial pulse. Then quickly lift their arm upwards with your left hand. In a collapsing pulse, you will feel a strong tapping when the arm is elevated.(Classically a sign of AR, but other causes include patent ductus arteriosus; high-output states e.g. anaemia, thyrotoxicosis; and physiological states e.g. pregnancy, fever.)
  • Note that you would check the blood pressure
  • You may find a wide pulse pressure in AR; or a narrow pulse pressure in AS

Head and neck

  • Face: malar flush – flushed cheeks that may be seen in MS
  • Eyes
    • Ask permission from the patient then pull down the lower eyelid to look for conjunctival pallor (anaemia)/haemorrhages (IE)
    • Also look in the eye for corneal arcus, and around it for xanthelasma (periorbital yellow plaques; hyperlipidaemia)
  • Mouth: look for central cyanosis under tongue (hypoxia), petechial haemorrhages (IE), poor dental hygiene (IE risk), high-arched palate (Marfan syndrome)

  • Neck
    • JVP: ask the patient to rest their head back and turn head slightly, then look for double pulsation of internal jugular vein – up to 3cm above sternal angle is normal

Causes of a raised JVP (PQRST)

  • Pulmonary hypertension/PE/PS/pericardial effusion
  • Quantity of fluid i.e. overload
  • RVF
  • SVC obstruction
  • Tamponade/TR

  • Hepatojugular reflux test: apply pressure over RUQ by pressing with one hand and observe JVP (transient rise = normal; sustained rise = RVF)
  • Carotid pulse feel the character and volume
  • A slow-rising low volume pulse is characteristic of AS;
  • A bounding/collapsing pulse is felt AR or patent ductus arteriosus
  • Other signs: Corrigan’s sign (visible carotid pulsation; AR), de Musset’s sign (head bobbing in time with pulse; AR)

Chest

  • Inspect the chest closely
  • Look for chest deformities (pectus excavatum/carinatum)
  • Scars – ask them to lift up arms ± breasts
  • Check for devices (pacemaker, ICD, loop recorder)
  • Look for visible apex beat, and distended veins over precordium (superior vena cava obstruction)

  • Palpation
    • Apex beat position: palpate with whole hand, then localise to a finger
    • Count down intercostal spaces with the other hand
    • Impalpable apex beat = DOPE
      • Dextrocardia
      • Obese
      • Pericardial effusion
      • Emphysema
    • Displaced = LV dilation (e.g. due to MR or AR), cardiomegaly, or displacement due to RV enlargement or mediastinal shift)
    • Note the apex beat character
      • Heaving = high pressure pulsation in left ventricular hypertrophy, e.g. due to AS or systemic hypertension
      • Thrusting = large area pulsation in volume overload, e.g. due to MR or AR
      • Tapping = palpable S1 in MS

NB: if you cannot feel the it, roll patient into left lateral position and palpate during expiration to determine character.

  • Parasternal heave: place the heel of your right hand over the patient’s left lower parasternal edge with a straight elbow (parasternal heave = RV hypertrophy, e.g. due to pulmonary hypertension or PS)
  • Thrills and palpable heart sounds: palpate over valve areas with the pads of the fingers (AS thrill most common; palpable S2 over pulmonary area = pulmonary hypertension)
  • Auscultation: auscultate all heart valves, using the stethoscope diaphragm unless otherwise stated.
  • Simultaneously palpate the carotid pulse
  • Note S1 and S2 intensity and any splitting, S3/S4, clicks/snaps, rubs, and murmurs. If you hear a murmur, note: site heard loudest, pulse timing, character, volume and radiation.

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Where to auscultate by heart valve
  • Mitral valve: with patient lying at 45˚, feel apex beat then place stethoscope over it. Then listen in the left axilla for radiation (MR). Then roll patient onto their left side and listen with the bell over the apex on expiration (accentuates MS low tones).
  • Tricuspid valve
  • Pulmonary valve + specifically listen for loud S2 in this position (loud pulmonary S2 = pulmonary hypertension)
  • Aortic valve: listen with patient lying at 45˚. Then listen over right carotid artery with breath held for radiation (AS). Then sit patient forward and listen at Erb’s point (3rd intercostal space, left sternal edge) on expiration (accentuates AR).

Murmurs: right valves heard better at full inspiration, left valves at full expiration.

Do not put stethoscope on top of the breast – listen in inframammary fold.

Systolic murmurs (e.g. MR and AS) radiate. Diastolic murmurs (e.g. MS and AR) are quiet and need a manoeuvre to accentuate them.

Finally

  • Pulmonary oedema: auscultate lung bases for fine crepitations while patient is still sitting (LVF)
  • Peripheral oedema: push over the sacrum for 10 seconds, then run finger over feeling for indent (occurs in RVF and hypoalbuminaemia)
  • Do the same on the tibia (note how far it extends)
  • Also look at the legs for a vein grafting scar if the patient had a midline sternotomy scar (indicates they had a CABG)

To complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would examine for peripheral pulses, feel for hepatomegaly (RVF), look at observation charts and dipstick the urine(haematuria in IE).’
  • Summarise and suggest further investigations you would consider after a full history

Why don’t you test your knowledge on the causes of valve pathology?

How about some advanced clinical findings?

Now try some OSCE stations!

  1. Cardiac exam
  2. Systolic murmur
  3. AF
  4. Valve replacement
  5. There’s hundreds of stations here

Picture references

Peripheral cyanosis: 2011 James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

Clubbing: 2009 Desherinka, licensed under the Creative Commons Attribution-Share Alike 4.0 International, 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic license and GNU Free Documentation licence 1.2

Splinter haemorrhages: 2010 Splarka, in public domain

Osler’s nodes: 2010 Robert J Galindo, licensed under the Creative Commons Attribution-Share Alike 4.0 International, 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic license and GNU Free Documentation licence 1.2

Janeway lesions: 2015 Warfieldian; licensed under the Creative Commons Attribution-Share Alike 4.0 International license

Corneal arcus: 2008 Loren A Zech Jr and Jeffery M Hoeg; licensed under the Creative Commons Attribution 2.0 Generic license, edited

Xanthelasma: 2005 Klaus D. Peter; licensed under the Creative Commons 3.0 Germany licence

Pectus excavatum: 2006 Ahellwig, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license and GNU Free Documentation licence 1.2

Pectus carinatum: 2010 Tolson411, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license, edited

Pitting oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

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