Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Position the patient at 45° with their chest exposed Ask if the patient currently has any pain General inspection Bedside – treatments or adjuncts? – GTN spray / O2 / medication / mobility aids Check the patient is comfortable at rest Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis Inspect chest – scars or visible pulsations? (remember to look underneath arms for thoracotomy scars and for small scars from minimally invasive surgery) Inspect legs – scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes Hands Hands out with palms facing downwards Splinter haemorrhages – reddish/brown streaks on the nail bed – bacterial endocarditis Finger clubbing: 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 (Schamroth’s window) When finger clubbing is present this window is lost Finger clubbing has a number of causes including infective endocarditis and cyanotic congenital heart disease Hands out with palms facing upwards Colour – dusky bluish discolouration (cyanosis) suggests hypoxia Temperature – cool peripheries may suggest poor cardiac output/hypovolaemia Sweaty/Clammy– can be associated with acute coronary syndrome Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis Osler’s nodes – tender red nodules on finger pulps/thenar eminence – infective endocarditis Tar staining – smoker – risk factor for cardiovascular disease Xanthomata – raised yellow lesions – often noted on tendons of the wrist – caused by hyperlipidaemia Capillary refill time – normal is <2 seconds – if prolonged may suggest hypovolaemia Pulses Radial pulse – assess rate and rhythm Radio-radial delay: Palpate both radial pulses simultaneously They should occur at the same time in a healthy adult Radio-radial delay can be associated with subclavian artery stenosis (e.g. compression by a cervical rib) or aortic dissection Collapsing pulse – associated with aortic regurgitation First, ensure the patient has no shoulder pain Palpate the radial pulse with your hand wrapped around the wrist Raise the arm above the head briskly Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation This is a water hammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g. AR/PDA) or high output states (e.g. anaemia/AV fistula/thyrotoxicosis) Brachial pulse – assess volume and character Blood pressure: Measure blood pressure and note any abnormalities – e.g. hypertension/hypotension Narrow pulse pressure is associated with aortic stenosis Wide pulse pressure is associated with aortic regurgitation Often you won’t be expected to actually carry this out (due to time restraints) but make sure to mention that you’d ideally like to measure blood pressure in both arms Carotid pulse: Assess character and volume – e.g. slow rising character in aortic stenosis It’s often advised to auscultate the carotid artery for a bruit before palpating, as theoretically palpation may dislodge a plaque which could lead to a stroke However, if you perform carotid auscultation at this point, remember that the ‘bruit’ may actually be a radiating murmur! Jugular venous pressure (JVP) 1. Ensure the patient is positioned at 45° 2. Ask patient to turn their head away from you 3. Observe the neck for the JVP – located inline with the sternocleidomastoid 4. Measure the JVP – number of centimetres from the sternal angle to the upper border of pulsation Raised JVP may indicate – fluid overload / right ventricular failure / tricuspid regurgitation Hepatojugular reflux: Apply pressure to the liver Observe the JVP for a rise In healthy individuals, this should last no longer than 1-2 cardiac cycles (it should then fall) If the rise in JVP is sustained and equal to or greater than 4cm this is a positive result A positive hepatojugular reflux sign is suggestive of right-sided heart failure and/or tricuspid regurgitation This is very uncomfortable to perform correctly – an examiner will often prevent you performing it but remember to mention it! Face Eyes Conjunctival pallor – anaemia – ask the patient to gently pull down their lower eyelid Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia Mouth Central cyanosis – bluish discolouration of the lips and/or the tongue Angular stomatitis – inflammation of the corners of the mouth – iron deficiency High arched palate – suggestive of Marfan syndrome – ↑ risk of aortic aneurysm/dissection Dental hygiene – important if considering sources for infective endocarditis Close inspection of the chest Scars: Thoracotomy – minimally invasive valve surgery Sternotomy – CABG / valve surgery Clavicular – pacemaker (can be either side, so remember to check both) Left mid-axillary line – subcutaneous implantable cardioverter defibrillator (ICD) Chest wall deformities – pectus excavatum / pectus carinatum Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy Palpation Apex beat: Located at the 5th intercostal space / midclavicular line Palpate the apex beat with your fingers (placed horizontally across the chest) Lateral displacement suggests cardiomegaly Heaves: A parasternal heave is a precordial impulse that can be palpated Parasternal heaves are present in patients with right ventricular hypertrophy 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 Thrills: A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur) You should assess for a thrill across each of the heart valves in turn 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 Auscultation Auscultate the four valves A systematic routine will ensure you remember all the steps whilst giving you several chances to listen at each valve area. Your routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps. 1. Palpate the carotid pulse to determine the first heart sound. 2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope: Mitral valve – 5th intercostal space – midclavicular line (apex beat) Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge Pulmonary valve – 2nd intercostal space – left sternal edge Aortic valve – 2nd intercostal space – right sternal edge 3. Repeat auscultation across the four valves with the bell of the stethoscope. 4. Auscultate the carotid arteries with the patient holding their breath to check for radiation of an aortic stenosis murmur (this is known as an accentuation manoeuvre). 5. Sit the patient forwards and auscultate over the aortic area during expiration to listen for the murmur of aortic regurgitation (this is known as an accentuation manoeuvre). 6. Roll the patient onto their left side and listen over the mitral area with the bell during expiration for mitral murmurs (regurgitation/stenosis). To complete the examination Auscultate lung bases: Crackles may suggest pulmonary oedema (e.g. secondary to left ventricular failure) Consider chronic lung diseases if the patient has no other signs of fluid overload (e.g. pulmonary fibrosis) Sacral oedema/pedal oedema – may indicate right ventricular failure Thank the patient Wash hands Summarise findings
