Cardiovascular Examination

Cardiovascular Examination

6 minutes

Please examine the cardiovascular system/ heart or pulse. 

Introduction + End of bed

WINDEC:

• Wash hands

• Introduce yourself,

• Explain the examination, ask for consent & pain, smile (!)

Exposure

• It is important to ensure adequate exposure for inspection- 45 degrees lying on bed, ask for consent for a male to be topless and female to be down to bra (maintain dignity)

Inspection

End of the bed

• Medications, oxygen

• Audible clicks from end of bed

• Pallor, wob, scars

Chest, abdomen & back

• Bruising - anticoagulation

Peripheral

Lower limbs

• Peripheral oedema (check for pain prior)

• Scars from vein harvesting for CABG

Hands

• Warmth, tendon xanthamata, finger clubbing, tobacco staining, janeway lesions- palms of hands (like Jane- not painful), oslers nodes- painful lesions pads, palmar erythema;

• Radial pulse- volume, rate, rhythm; radial - radial delay, ask for BP & would examine radial- femoral delay 

• Collapsing pulse- check for shoulder pain prior [fail station if not]

Arms

• Lines or fistulas

Neck

• JVP: raised if > 3cm above sternal notch [at 45 degrees], normal to have a hepatojugular reflex

• Carotid pulse

Face

• Face: mallor flush

• Eyes: conjunctival pallor, corneal arcus and xanthelasma

• Mouth: central cyanosis (tongue), dentition, high arch palate (Marfan's)

Chest 

Anterior

Inspection

• Scars: median sternotomy, lateral thorocotomy; including axilla

• Work of breathing, central cyanosis

Palpation

• Apex beat- 5th IC mid clavicular line + count (below clavicle is 2IC) + left ventricular heave, if unable to feel- move to auxilla

• Thrills in four heart areas: 2IC

• Heaves- right ventricular

Auscultation

• Listen without stethoscope for audible metallic click (single or double)

• Heart Sounds 

  • Time with carotid pulse

  • All four areas- aortic & pulmonary: left & right 2nd IC mid clavicular line (MCL), tricuspid 4th left IC MCL, mitral 5th IC MCL

    • Bell & Diaphragm

    • Inhale and hold, exhale and hold;

  • Auxilia 

  • Roll onto left side: 

    • Mitral Stenosis - inspiration, apex, bell at apex

    • Feel apex beat again

  • Carotid- radiation of murmur, carotid bruit unable to be heard

  • Aortic Regurgitation- held inspiration, leaning forward, at aortic 2nd IC, diaphragm

Posterior

• Palpate for sacral oedema

• Chest crackles

• Consider left scapular (posterior) for PDA- machinery murmur

Conclusion

Thank patient, gel hands, offer clothes back. Complete exam BP, HR and consider assessing radial femoral delay. 

Signs

Peripheral

Hands

• Janeway lesions: IE, non painful 

• Osler nodes: painful IE

Pulse

• Slow rising: Aortic Stenosis 

• Collapsing pulse: aortic regurgitation, patent ductus arteriosus, hyperdynamic circulation (pregnancy, anaemia, liver cirrhosis)

JVP:

• Elevated: fluid overload - heart, liver, renal failure; right heart failure/ pulmonary hypertension

• CV waves: severe TR

Chest

Apex beat

• Distal and thrusting: Mitral Regurgitation

• Un-displaced and heaving (LV Heave): Aortic Stenosis 

• Tapping: Mitral Stenosis 

Thrill: palpable murmur

Heave

• RV Heave- right ventricular hypertrophy

Murmurs

• Systolic Murmurs:

  • Aortic Stenosis: ejection systolic, radiating to the carotids, loudest expiration & RLSE 2nd intercostal space, bounding pulse, elderly; un-displaced/ heaving apex beat

  • Aortic Sclerosis: ejection systolic- shorter and doesn't radiate to carotids

  • Mitral Regurgitation: pansystolic, radiating auxilla, loudest expiration & apex, distal/ thrusting apex beat

  • Ventricular Septal Defect: pansystolic, loudest LLSE 4th intercostal space, young, quiet P2 (nil pulmonary hypertension)

  • HOCM- young, ejection systolic loudest at LLSE 4th intercostal space, exacerbated by valsalva manouvres

  • Pulmonary Stenosis- very rare, ejection systolic, loudest inspiration at LLSE 2nd intercostal space; associated congenital abnormalities

  • Tricuspid Regurgitation- pansystolic, loudest at LLSE 4th intercostal space, louder with inspiration, pulmonary hypertension - loud P2 + raised JVP

• Diastolic Murmur

  • Aortic Regurgitation: early diastolic, loudest RLSE 2nd intercostal space

  • Mitral Stenosis: mid diastolic grumble, apex beat, loudest inspiration

Clinical Presentations 

Core Presentations

1. Aortic Stenosis (& Aortic sclerosis)

2. Mitral Regurgitation

3. Metallic Aortic Valve Replacement

4. Metallic Mitral Valve Replacement

5. Ventricular Septal Defect

6. Aortic Regurgitation 

7. Mitral Stenosis

8. Marfan's Syndrome, Ehlers Danlos syndrome (EDS) - MR, AR

9. Atrial Fibrillation

10. Normal examination

Stable signs that can present

• Dextrocardia

Aortic Stenosis

• Signs

  • Bounding slow rising pulse

  • Ejection systolic murmur, radiating to the carotids

  • Undisplaced and heaving apex beat

Written in 2026