Remember to link any assessment to your introductory line about the patients’ history or to anything elicited in your history.
Introduce yourself
Ask permission to perform the examination
Position the patient and expose patient appropriately
Start at the end of the Bed – Inspection
SOB? Count respiratory rate.
If secondary to heart failure, then this is NYHA class IV heart failure
Class I :Asymptomatic
Class II :Breathless on significant exertion
Class III :Breathless on mild exertion
Class IV :SOB at rest
Walking Aids, Oxygen
Peripheral oedema
Medication around the bed
Intravenous cannula
Cyanosis
Scar on chest
Evidence of vein harvesting from legs
Malar rash?
Any other clues?
E.g. Rheumatoid Hands/ Lupus Rash
Marfan’s Syndrome (AD, Male, Risk Aortic regurgitation and Aortic Dissection: famous patients: Abraham Lincoln/ Paganini)
Turners Syndrome [female/ coarctation of aorta/ wide carrying angle / shield like chest/ wide spaced nipples/ learning difficulties]
Downs Syndromeàthink VSD
Ankylosing Spondylitisà Aortic regurgitation
Examination of the hands
- Clubbing – Congenital cyanotic heart disease, endocarditis
- Splinter haemorrhages
- Oslers nodes. Janeway lesions
- Nail fold infarcts
- Arachnodactyl (? Marfans)
- Quinckes sign (pulsatile nailbeds in aortic regurgitation)
- Peripheral cyanosis
- Tendon xanthomata
Examination of the Pulse
| Condition | Rate | Rhythm | Volume | Radio Radial Delay | Collapsing | Differential |
| Sinus Rhythm | 60-100 | Regular* Not if ectopics | Normal | – | – | |
| AF Fast | >100 | Irregularly irregular | Varies in volume from beat to beat | – | – | SR with ectopics (need to do an ECG) |
| AF rate controlled | 60-100 | Irregularly irregular | Varies in volume from beat to beat | – | – | Can feel like sinus rhythm |
| Aortic stenosis | 60-100 | Regular (remember high incidence AF) | Slow rising (Delayed LV emptying leads to delayed surge) | – | – | |
| Aortic regurgitation | 60-100 | Regular | Collapsing | – | yes | |
| Mixed AoV disease (Bisferiens) | 60-100 | Regular (unless AF) | Combination of slow rising/ collapsing | – | +/- | |
| Bradycardia | <50 | Regular | e.g. Drugs (Beta blockers/ Verapamil/ digoxin toxicity CHB (complete heart block) | |||
| 2nd degree heart block | Varies | Variable | Can be Mobitz I (gradually increasing PR interval and then dropping a beat) Mobitz 2 (fixed 2:1 3:1 block with fixed PR interval) | |||
| Sinus Rhythm with ectopics | 60-100 | Irregular again with no pattern | Ectopic beats can have irregular volume but normal sinus beats are regular in rate and volume |
Pulsus alternans in poor LV function
Pulsus paradoxus (>10mmHg fall in pulse pressure during inspiration) – tamponade,
pericardial constriction, status asthmaticus.
Remember to check blood pressure
Examination of the face
- Signs of thyroid eye disease
- Xanthelasma: Rice crispy type changes around the outside of the margin of the eye. Corneal arcus can also suggest hyperlipidaemia
- Jaundice: prosthetic valves can produce a low grade haemolysis
- Malar rashà mitral stenosis. Rare. Commoner in patients born outside of the UK.
- Central cyanosis
Chest Examination
| Chest Scars | Differential | Other Clues | Notes |
| Midline Sternotomy | Valve replacement | Bruising (warfarin) Bio-Prosthetic Heart sound’s Normal! Metallic Heart sound [as the valve shuts] | |
| CABG | Vein harvesting scars should be present on the legs [NB can use internal mammary artery which may not leave a scar] | ||
| Other Mediastinal surgery | CABG& Valve replacement at the same time! | ||
| Cardiac Transplant | Signs of immunosupressive treatment (e.g. bottle of Azathioprine by the bedside/ prednisolone/ clue in the introduction) | ||
| Lung Surgery | Tumour resection Lobectomy | Indications for lobectomy include Abscess Cancer Bronchiectasis (focal segment) Suspicious lesion | |
| Lung Transplant | Clues from the history. | ||
| Oesophagectomy | May be other drain scars/ other lateral thoracotomy scars | ||
| Lateral Thoracotomy | Valvuloplasty (open) | ||
| Lung surgery | Resection: cancer- see above | ||
| Previous open CPR |
Apex Beat Characteristics
Localise the maximal point of the impulse and then define its location in relation to anterior axilliary line/ mid clavicular line. Apex beat of normally 5th intercostalsspace, midclavicular line.
| Nature | Features |
| Just Palpable Apex / Impalpable | Poor LV function (left heart failure) Obesity COPD and hyperinflated chest Dextrocardia (palpate the other side Pericardial effusion |
| Heaving | Prominent apex. Commonly occurs in left ventricular outflow tract obstruction such as HOCM (hypertrophic obstructive cardiomyopathy) Or AS |
| Tapping Apex (not displaced) | Mitral stenosis |
| Parasternal Heave | Occurs in Right Ventricular hypertrophy |
| Thrill (Palpable Murmur) | E.g. aortic stenosis/ pulmonary hypertension |
Heart Sounds
S1= Closure mitral and tricuspid valves
S2= Closure of Aortic Valve (A2) then Pulmonary (P2)
Added sounds:
- Mid systolic click= mitral valve prolapse (with a late systolic murmur after the valve has prolapsed)
- Opening snap= early diastolic murmur of mitral stenosis
- Prosthetic S1= Mitral valve replacement
- Prosthetic S2= Aortic valve replacement
- Loud P2= Pulmonary hypertension
- Soft S2= Aortic stenosis
- Loud S1= Tapping apex associated with Mitral stenosis
- S3= early diastolic sound heard when there is rapid ventricular filling. The S1-S2-S3 is termed a gallop rhythm and occurs in congestive cardiac failure
- S4= Occurs before S1 and is due to atrial contraction against a stiff ventricle (due to AS / systemic hypertension)
Murmurs
- Ejection systolic murmur (ESM)= innocent/AS/PS/HOCM/ASD/ Fever/ Aortic Sclerosis (associated with increased mortality from cardiac disease)
- Pansystolic murmur (PSM)= MR, TR, VSD [harsh and radiates all over precordium]
- Austin Flint= Aortic jet fluttering against the mitral valve leaflets (Therefore an early diastolic murmur)
Effect of respiration
- Inspiration : Generally makes right sided murmurs louder
- Expiration: Generally makes left sided murmurs louder (e.g. AS ,MR)
Remember to lean patient forward for a time when auscultating
May need to ask them to hold their breath in/out
May need to consider asking them to lean on left lateral side to listen for mitral murmurs (in particular MS gets louder)
To conclude examination
I would like to auscultate the lung bases, examine for signs of peripheral oedema, examine the abdomen for signs of hepatomegaly (related to right sided heart failure) etc…….