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, exposure, 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 (in PACES exam offer to remove bra)

Inspection

End of the bed

• Medications, oxygen

• Audible clicks from end of bed

• Pallor, wob, scars

• Metabolic status/ smoking- risk factors for Coronary Artery Disease

Chest, abdomen & back

• Bruising - anticoagulation

• Scars

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

Face

• Face: mallor flush

• Eyes: conjunctival pallor, corneal arcus and xanthelasma

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

Neck

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

• Carotid pulse

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 (with Diaphragm)

  • Radiation

    • Auxilia 

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

  • Maneuvers

    • Mitral Stenosis - Roll onto left side, re-palpate apex beat, deep expiration & hold, auscultate with bell at apex

    • Aortic Regurgitation- Lean forward, diaphragm at aortic region (2IC RLSE), hold deep expiration

Posterior

• Inspect for Scars

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

• Palpate for sacral oedema

• Chest crackles

Conclusion

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

Presentations 

4 minutes

Core

1. Midline Sternotomy

   1. Metallic Aortic Valve Replacement

   2. Metallic Mitral Valve Replacement

   3. Heart Transplant

2. Bioprosthetic valve, CABG (normal examination)Murmur

   1. Aortic Stenosis 

   2. Aortic Sclerosis

   3. Mitral Regurgitation

3. Atrial Fibrillation

4. Congestive Heart Failure (CHF) 

Possible

1. Ventricular Septal Defect

2. Aortic Regurgitation 

3. Mitral Stenosis

4. Connective Tissue disease- Marfan's Syndrome, Ehlers Danlos syndrome (EDS) - MR, AR

5. Dextrocardia

Structure

• Signs

• Differentials

• Complications (CHF) + Aetiology (age, IE, Rheumatic Fever)

• Complete assessment: history, examination, observations

• Investigations: headline, bedside, body samples, imaging, interventions

• Management: headline, MDT, lifestyle, medication, surgery 

Aortic Stenosis

Signs

• • Bounding slow rising pulse

  • Ejection systolic murmur, radiating to the carotids

  • Un-displaced and heaving apex beat

I've examined Mr Jones' cardiovascular system today. My positive findings include an ejection systolic murmur loudest in the aortic region, louder with expiration and radiated to the carotid. My impression this is severe aortic stenosis due to the absence of S2, a slow rising pulse and an un-displaced heaving apex beat. 

These findings would be consistent with aortic stenosis. My differentials for an ejection systolic murmur would be aortic sclerosis which has a murmur that is shorter and doesn't radiate to the carotids. My differentials for a systolic murmur and are mitral regurgitation but which is pansystolic, loudest at the apex and has a normal pulse and displaced and thrusting apex beat; VSD and HOCM, which are both pansystolic and in younger patients. 

Mr Jones is not in heart failure and was euvolaemic on examination suggesting the aortic valve may be functioning well. I did not find any stigmata of infective endocarditis or suggestion of an underlying aetiology. Therefore, given Mr Jones' age, I suspect this is age relate degeneration. 

In order to fully assess the valve function I would like to take a history, asking about syncope, angina and dyspnoea. I would also want to ask about exercise tolerance and frailty. I would like to complete my examination looking at the other body systems and looking at the HR and BP, expecting a narrow pulse pressure. 

The primary investigations would be an ECHO to characterise the stenosis severity. Severe features would be a the mean flow velocity greater than 40, a peak flow velocity greater than 60 and sign of left ventricular systolic dysfunction. Bedside ECG may show left ventricular hypertrophy and left axis deviation, CXR and BNP may shows signs of heart failure. Baseline bloods of FBC to look for anaemia, urea & electrolytes to look at the sodium & potassium prior to starting diuretics, liver function tests before starting medications and CRP for infection. 

The management would be focused around surgical management, either open heart surgery with either a mechanical or pig valve or  a trans-arterial arroach- a TAVI. As this individual is greater than 75 years old TAVI would be the preferred and the decision would be made by the MDT. The MDT contains a consultant cardiologist, cardiothoracic surgeon, anesthetist and allied health team of physio, dietician, OT and SW. Lifestyle advice would include stopping smoking, low salt and balanced low processed diet and regular exercise to prevent frailty. Medical management has limited success and follows similar pillars of managing congestive heart failure with duiretics if overloaded and cautious betablockers and ace inhibitors.

c.3:30 mins

Written in 2026