Palms: look for Osler’s nodes (painful purple papules on pulps; caused by IE), and Janeway lesions (erythematous macules on palms; caused by IE)
Inspect for bruising (may be seen in patients on anticoagulation, which may be required for AF or metallic heart valve replacements)
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
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)
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
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)
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)
Apex beat position: palpate with whole hand, then localise to a finger
Count down intercostal spaces with the other hand
Impalpable apex beat = DOPE
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.
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).
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.
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)
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?
What are the causes of aortic stenosis?
What are the causes of aortic regurgitation?
What are the causes of mitral regurgitation?
What are the causes of mitral stenosis?
How about some advanced clinical findings?
Name the five eponymous signs of aortic regurgitation?
What is an Austin Flint murmur
How would you differentiate between aortic stenosis and aortic sclerosis?
How would you differentiate between mitral regurgitation and tricuspid regurgitation?