CARDIOVASCULAR EXAMINATION

INTRODUCTION

Introduce self with full title and position

Ask patients name and DOB

Explain procedure and gain consent

o Ive been asked to do an examination of your CV system today, that will
just involve me having a look at your hands, feeling your pulses and having
a listen to your heart Is that ok?

Ask if patient is comfortable

Wash hands
INSPECTION

GENERAL INSPECTION
o Do they look ill? If so, in what way? Are they short of breath at rest? Is there
cyanosis?
o Look for:

Scars

Patient comfort

Shortness of breath/ tachypnoea

Adjuncts around bed

INSPECTION OF THE HANDS

o Temperature (may be cold in CCF)
o Colour indicating peripheral cyanosis
o Nails

Tar staining and splinter haemorrhages, signs of finger clubbing,

blue discolouration (if peripheral perfusion is poor)

Splinter haemorrhage DDx rheumatoid arthritis,

vasculitis, trauma, bacterial endocarditis

Clubbing CV DDx cyanotic congenital heart disease,

infective endocarditis
o Look in palmar crease for pallor sign of anaemia
o Oslers nodes and Janeway lesions
o Xanthomata (often seen on tendons in the wrist)

PERIPHERAL PULSES
o Rate: normal = 60-100
o Rhythm

Regular

May be variation with inspiration and expiration

Irregularly irregular

Synonymous with atrial fibrillation)

Regularly irregular

Pulsus bigeminus (regular ectopic beats resulting in

alternating brief gaps and long gaps between pulses)

Wenckebachs phenomenon (increasing time between each

pulse until one is missed 2nd degree (Wenckebachs) heart
block

Regular with ectopics

Intermittent interruptions
o Character/waveform (best assessed in carotid)

Aortic stenosis: slow rising plateau pulse

Aortic regurgitation: collapsing warterhammer pulse

Hypertrophic cardiomyopathy: jerky pulse; pulse may peter out

Pulsus bisferiens: waveform with 2 peaks (coexistence of AR and

AS)

Pulses alternans: alternating strong and weak pulsation

(synonymous with failing left ventricle)

Pulsus paradoxicus: pulse weaker during inspiration

Cardiac tamponade, status asthmaticus, constrictive

pericarditis

ARM
o
JVP
o
o

Ask patient to turn head and e.g. look up to the corner of the room

Look for visible pulsation

If negative, perform the hepato-jugular reflex manoeuvre

Ask if patient has abdominal discomfort

Im just going to press on your tummy now, if you could keep

looking to the corner of the room
Measure JVP from sternal angle to highest point of visible pulsation with
patient at 45 (RA lies 5cm below sternal angle. JVP = x +5cm; n 8cm,
expressed as e.g. 3cm raised)

INSPECTION OF THE FACE

o EYES

Inspect eyes for xanthelasma and corneal arcus

Check conjunctivae for pallor indicating anaemia

o

Ask to test blood pressure

Moving up the arm, I would then test blood pressure

MOUTH

Inspect cheeks for malar flush

Look at lips for peripheral cyanosis

Tongue for central cyanosis

Ask patient to protrude tongue and open wide; look for high-arched
palate is Marfans suspected

CLOSE INSPECTION OF THE CHEST

o Check for scarring, pacemaker and chest wall abnormalities e.g. pectus
excavatum/ carinatum
o Check for visible pulsations

PALPATION

Palpate for apex beat in the 5th IC space in the mid-clavicular line
o State if this is normal

Palpate for murmurs, thrills or heaves (left parasternal (RV) heave RV

hypertrophy)
o Mitral and tricuspid areas
o Aortic and pulmonary areas

If systolic: aortic stenosis, ventricular septal defect, mitral

regurgitation

If diastolic: mitral stenosis

Palpate carotid
ASCULTATION

Listen for apex beat

Then 4 heart areas turn patient left lateral for mitral and listen with bell and
diaphragm
o State which area you are testing

Sit patient forward to auscultate aortic regurgitation over left sternal

border (in full expiration and holding breath)
ENDING THE EXAMINATION

Thank patient

Wash hands

Summarise

Candidate Task 1:

Perform a cardiovascular examination on this patient

State what you are doing as you proceed and discuss your findings both
positive and negative with the examiner.
Do not examine the limbs or hands in this patient.
You have 5 minutes

Introduces oneself/ Identifies patient

Explains procedure/consents
Inspection
Cyanosis, lips and tongue
Differentiates central from peripheral
cyanosis
Positions correctly and identifies JVP
Demonstrates hepato-jugular reflux
Chest for scars etc
Palpation
Apex beat
Locate by palpation
Counts inter-costal spaces
Left parasternal (RV) heave??
Thrill?
Auscultation
Mitral area
Turns patient to left lateral
Tricuspid area
Pulmonary area
Aortic area
Listens over carotid(s)
Sits person forwards, in expiration
Identifies sites:
Hand wash before and after examination
Overall assessment of performance
please circle:
Fail

Not done / incorrect

0
0

Done / correct
1
1

0
0

1
1

0
0
0

1
1
1

0
0
0
0

1
1
1
1

0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1

Borderline

Pass

Candidate Task 2:

Perform a cardiovascular examination, including radial pulse check, on this

patient
State what you are doing as you proceed and discuss your findings both
positive and negative with the examiner.
Do not examine the face, neck, hands, and feet or check the blood
pressure in this patient.
You have 5 minutes

Not done / incorrect

0
0

Introduces oneself/ Identifies patient

Explains procedure/consents
Inspection:
Looks for tachypnoea
0
Chest for scars etc
0
Radial Pulse:
Rate
0
Rhythm
0
Volume
0
Character
0
Palpation
Apex beat
0
Locate by palpation
0
Counts inter-costal spaces
Left lateral for character
0
Left parasternal (RV) heave?
0
Thrill?
0
Auscultation
Mitral area
0
Turns patient to left lateral
0
Tricuspid area
0
Pulmonary area
0
Aortic area
0
Sits person forwards, in expiration
0
Hand wash before and after examination
0
Overall assessment of performance please circle:
Fail
Borderline

Done / correct
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Pass

Candidate Task 3:

Perform a cardiovascular examination to look for evidence of heart failure on

this patient, using palpation and inspection only
State what you are doing as you proceed and discuss your findings both
positive and negative with the examiner.
Do not use your stethoscope on this patient - no auscultation
Do not check their Blood Pressure
You have 5 minutes
Not done / incorrect
0
0

Introduces oneself / Identifies patient

Explains procedure / consents
Inspection:
Looks for tachypnoea
0
Cyanosis
0
Differentiates central from peripheral
0
cyanosis
Correctly positions for JVP assessment
0
Correctly measures height of JVP
0
Demonstrates hepato-jugular reflux
0
Chest for scars etc
0
Palpation:
Apex beat
0
0
Locate by palpation
0
Counts inter-costal spaces
Left lateral for character
0
Left parasternal (RV) heave?
Thrill?
0
Oedema:
Ankle oedema
0
Checks pitting
0
Sacral oedema
0
Checks pitting
0
Asks to examine for hepatomegaly
0
Hand wash before and after examination
0
Overall assessment of performance please circle:
Fail
Borderline

Done / correct
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Pass