The Cardiovascular Exam

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


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

ConditionRateRhythmVolumeRadio Radial DelayCollapsingDifferential
Sinus Rhythm60-100Regular* Not if ectopicsNormal 
AF Fast>100Irregularly irregularVaries in volume from beat to beatSR with ectopics (need to do an ECG)
AF rate controlled60-100Irregularly irregularVaries in volume from beat to beatCan feel like sinus rhythm
Aortic stenosis60-100Regular (remember high incidence AF)Slow rising (Delayed LV emptying leads to delayed surge) 
Aortic regurgitation  60-100RegularCollapsingyes 
Mixed AoV disease (Bisferiens)60-100Regular (unless AF)Combination of slow rising/ collapsing+/- 
Bradycardia  <50Regular   e.g. Drugs (Beta blockers/ Verapamil/ digoxin toxicity CHB (complete heart block)
2nd degree heart blockVariesVariable   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 ectopics60-100Irregular again with no patternEctopic 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 ScarsDifferentialOther CluesNotes
Midline SternotomyValve replacementBruising (warfarin) Bio-Prosthetic Heart sound’s Normal! Metallic Heart sound [as the valve shuts]     
 CABGVein harvesting scars should be present on the legs [NB can use internal mammary artery which may not leave a scar] 
 Other Mediastinal surgeryCABG& Valve replacement at the same time! 
 Cardiac TransplantSigns of immunosupressive treatment (e.g. bottle of Azathioprine by the bedside/ prednisolone/ clue in the introduction) 
 Lung SurgeryTumour resection LobectomyIndications for lobectomy include Abscess Cancer Bronchiectasis (focal segment) Suspicious lesion
 Lung TransplantClues from the history. 
 OesophagectomyMay be other drain scars/ other lateral thoracotomy scars 
Lateral ThoracotomyValvuloplasty (open)  
 Lung surgeryResection: 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.

Just Palpable Apex / ImpalpablePoor LV function (left heart failure) Obesity COPD and hyperinflated chest Dextrocardia (palpate the other side Pericardial effusion
HeavingProminent apex. Commonly occurs in left ventricular outflow tract obstruction such as HOCM (hypertrophic obstructive cardiomyopathy) Or AS
Tapping Apex (not displaced)Mitral stenosis
Parasternal HeaveOccurs 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)


  • 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…….