CARDIOVASCULAR EXAM STEPS

1. Introduce yourself to the patient

“Hello, my name is your name. I am a your position and I would like to examine your chest as
well look at your hands feet and face, is that ok? What is your name and age?”

2. Expose and position the patient

“Patient’s name, I want to be able to see your entire chest and back as well as your legs up to
your knees. Can I prop you up to sit at 45 degrees?”
Remove patient’s shirt, expose calves and feet and prop head of bed to 45 degrees

3. General inspection from the foot of the bed

General body habitus: obese, wasted, pathognomonic of a particular disease e.g. Xanthelasma,
mitral facies etc. and
Are there adjuncts: cardiac monitor, nitro glycerine spray, sputum cup

4. Move to the right side for closer inspection of the chest wall:
Look for scars (midline sternotomy), pacemaker, gynecomastia etc.

5. Inspect the hands:

Palmar side: pallor, warmth/cold, stigmata of infective endo
Dorsal side: skin colour
Nails: pallor, cyanosis, clubbing, splinter haemorrhages

6. Check the radial pulse:

Rate, rhythm and character
Check for R-R, R-F delay, F-F delay

7. Check for collapsing pulse:

Occlude radial pulse with palmar aspect of Lt hand metacarpal-phalangeal joints
“Do you have any pain in your shoulder? I am going to lift your arm up, don’t assist or resist
me.” You may use right hand to support the elbow.
Pause with the hand elevated to feel for the water-hammer effect of the pulse bounding
against your hand.
Then lower the arm back onto the bed and pause again to ensure you feel the pulses return to
normal.

8. Ask for the patient’s blood pressure

9. Assess the jugular venous pulse:

Ask the patient to turn their face away from you “Patient’s name, I want you to turn your face
away from me while I look at your neck.”
Using a light to visualize the rea of the neck between the two heads of the sternocleidomastoid
muscle, inspect for the subtle pulsation of the JVP
- Double, inward impulse
- Compressible
- Hepatojugular reflex
o Ask the patient if he/she has any pain in the abdomen, press firmly in cranial
direction (almost under) the Rt subchondral area, while watching the JVP o look
for the expected exaggeration in pulsation.
Once identified, indicate an imaginary horizontal line and then a perpendicular drop to the
sternal notch and estimate that distance. 0-4cm is normal. Anything higher suggests increased
Rt atrial volume/ pressure.

10. Inspect the face:

Pull eyelids down for pallor
Pull eyelids up and ask to look down for sclera: icterus
Open mouth and look with penlight with tongue lifted for central cyanosis, look at palate and
dentition

11. Assess for apex beat:

Place both hands on anterior chest, localize to the one hand, then 3 fingertips, then 1 finger.
Note character- normal/ thrusting/ tapping/ diffuse
Use the opposite hand to determine the 2nd intercostal rib space and “piano-play” down from
pinky to determine which intercostal space the apex beat is in.
Look for the mid-clavicular point and quickly trace an imaginary line down the chest wall to
determine if there is any deviation of the apex beat.

12. Assess for thrills and heaves:

Place the entire palmar surface of your hand as if feeling for the apex and then “walk your
hand” in a Z- pattern across the chest to assess for thrills.
Using the medial border of your hand, rest it on each side of the sternum and observe from the
level of the chest wall to assess for parasternal heaves.

13. Assess for the murmur of mitral stenosis:

Switch to the bell of the stethoscope at the mitral area and listen to heart sounds, noting the
character of S1 and S2; determine when S1 is by palpating the carotid pulse (just lateral to the
midline of the trachea, in the submandibular area) which will be synchronous with it.
Roll the patient into the Lt lateral decubitus position and auscultate for the murmur of mitral
stenosis.
14. Assess for the murmur of mitral regurgitation:
Put the patient back supine and switch to the diaphragm of your stethoscope.
Listen over the mitral area, again with the carotid pulse for timing and track right up into the
axilla to listen for the murmur of mitral regurgitation.

15. Listen for murmurs at the tricuspid space:

Continue to move the diaphragm of your stethoscope across the chest wall to the tricuspid
space and auscultate at the 4th left intercostal space for murmurs of the tricuspid valve and the
murmur of ventral septal wall defect.

16. Listen for the murmurs at the pulmonary space:

Continue to move the diaphragm of your stethoscope across the chest wall to the pulmonary
space and auscultate at the 2nd left intercostal space for murmurs of the pulmonary valve

17. Listen for murmurs at the primary aortic space:

Continue to move the diaphragm of your stethoscope across the chest wall to the primary
aortic space and auscultate at the 2nd right intercostal space for the murmur of aortic stenosis.
Track into the neck along the carotid to listen for radiation.

18. Listen for carotid bruits:

Switch your stethoscope to the bell and instruct the patient to hold their breath. Auscultate
over the carotids for bruits.

19. Listen for the murmur of aortic regurgitation:

Switch your stethoscope back to the diaphragm place it at the secondary aortic space- the 3rd
right intercostal space. Instruct the patient to sit up and forward “Patient’s name, I want you to
sit up and lean forward onto my stethoscope”. Listen while the patient is in that position, then
elicit the accentuation manoeuvre by instructing the patient “Breathe in, let it out slowly and
hold at the end.”

20. Auscultate the lung bases:

While the patient is still sitting forward, using the diaphragm of your stethoscope to auscultate
the lung bases bilaterally “take some normal breaths in and out”

21. Palpate for sacral oedema:

Press over the bony prominence of lumbar spinous processes to assess for pitting oedema.

22. Examine the legs:

Move down to the feet and palpate for the dorsalis pedis and posterior tibialis pulses
simultaneously
Then palpate for pitting oedema alone the anterior tibia surface distally, midway and
proximally.

23. Palpate for hepatomegaly:

(Ideally you want to lay the patient flat)
Palpate as you would from the right lower quadrant, cranially, moving such that the lateral
border of the hand is pressing in when the patient inspires until you reach the Rt costal margin.
You may percuss the liver span if you have time.

24. Thank the patient and cover them with the sheet.

To Do:
1. Fill in the table below, for each of the common murmurs:
Murmur Timing Character and change Grade Location heard +/- Associated/
with respiration best radiation distinguishing features
Mitral Stenosis Early
diastolic
Mitral To axilla
Regurgitation
Tricuspid 4th right
regurgitation intercostal
space
Ventral septal
defect
Pulmonary
stenosis
Aortic stenosis Crescendo/
(aortic sclerosis) decrescendo, louder
with expiration
Hypertrophic
Obstructive
cardiomyopathy
Aortic
regurgitation
Patent ductus
arteriosus
Atrial Septal
defect

2. Draw each murmur using the:

S1 |-----------S2 |----------------------S1|-----------S2|------------------ format

3. For each murmur, list up to 3 aetiologies for each and outline management principles
classified into
- Medical vs surgical
- Valve correction vs. valve replacement
- Which types of valves
- Mechanism of access, endoscopically or open