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Cardiovascular Examination 

Prepare patient
• Introduction
• Position semi-recumbent at 45º
• Whole chest exposed
General Inspection
General signs:
• Cachexia, dyspnoea, cyanosis
• Down (AVSD), Marfan’s (Ao), Turner’s (PS)
Other relevant diseases:
• Acromegaly, ankylosing spondylitis (AR)
Peripheral cyanosis
Clubbing (many causes including):
• Cyanotic congenital heart disease
• Infective endocarditis
• Atrial myxoma
• Lung Ca
• Chronic lung suppuration
o Lung abscess or empyema
o Bronchiectasis or CF
• Idiopathic pulmonary fibrosis
• Pleural mesothelioma
• Asbestosis
• Cirrhosis
• Coeliac disease
• SB lymphoma
• Thyrotoxicosis (acropachy)
• Idiopathic/familial
• Rarely:
o Pregnancy
o 2º Hyperparathyroidism
Stigmata of endocarditis
• Splinter haemorrhages
• Osler (painful) nodes & Janeway (painless) lesions
Radial Pulse
• Rate & rhythm. Compare left with right. Also feel for radio-femoral delay (coarctation).
Brachial BP
• Pulsus paradoxus – exaggerated drop (£10mmHg) in sysBP (& ↑HR) on inspiration.
Measured as BP diff between return of first intermittent sounds (K1 expiration ‘thuds’) &
regular K1 ‘thuds’ (expiration & inspiration). E.g. asthma, pericarditis, pericardial effusion.
Malar flush (MS, PS)
• Sclerae/Conjunctivae – comparative pallor (anaemia), jaundice
• Xanthelasma
• Argyll Robertson pupils (AR - small accommodating but not light reactive pupils, syphilis.)
• Cyanosis
• High arched palate (Marfan’s)
• Dentition (risk of endocarditis)
• CVP vertical height (norm£3cm) above sternal angle (~5cm above R atrium when at 45º)
• Wave form e.g. cannon a waves (3ºHB) , giant a waves (TS), large v waves (TR)
• Abdominojugular reflex – a sustained JVP rise during 10s mid-abdo pressure → RVF/LVF
• Bruits: carotid, thyroid, AS
• Pulse character & volume
o AS (small vol, slow rising, anacrotic)
o AR/PDA/hyperdynamic (collapsing),
o HOCM (jerky)



• Scars
• Pacemakers
• Deformity – pectus excavatum (Marfan’s)
• Visible pulsations                                                                                                                      
• Apex beat – not palpable in 50%. NB May be on R in dextrocardia.
o Position (usually 5ics 1cm medial to mcl, felt over area of 20c coin)
o Character – heaving (pressure loaded, AS or HT), thrusting (volume loaded, MR),
dyskinetic, double impulse (HOCM), tapping (of 1st HS - MS or rarely TS)
• Abnormal pulsations
o LSE: parasternal heave (RV or LA enlargement)
o Horizontally at base of heart for thrill (palpable murmur)
Heart sounds - Listen with bell & diaphragm, starting at apex/mitral area
• Loud S1: MS, tachycardia, short A-V conduction time
• Soft S1: MR, 1ºHB, LBBB
• Loud S2: HT, congenital AS, pulm HT
• Soft S2: Calcified AV, AR
• Splitting of S2:
o Increased: inspiration & RV emptying (RBBB, PS, VSD, MR)
o Fixed: ASD
o Reversed: delayed LV emptying (LBBB, AS, coarc, large PDA)
• S3: Mid-diastolic gallop rhythm. Rapid diastolic filling. Maybe normal in children/young
adults. Louder LSE (RVF) or apex (LVF)
• S4: Late diastolic gallop rhythm. ↓Ventricular compliance. LV S4 (AS, MR, HT, IHD,
elderly), RV S4 (pulm HT, PS)
• Opening snap: MV in MS soon after S2 in diastole before murmur
• Systolic ejection click: Early systole in congenital AS or PS before murmur
• Non-ejection systolic clicks: MVP, ASD, Ebstein’s anomaly
• Prosthetic valve sounds
Murmurs – Grade 1 to 6
• 4icsmcl (MV), 2icsRSE (AV), 2icsLSE (PV), 5icsLSE (TV)
• If systolic murmur ?radiates above clavicle to carotid
• If diastolic murmur ?radiates to axilla
• Pansystolic: MR, TR, VSD, aortopulmonary shunt
• Ejection systolic: AS, PS, HOCM, coarc, pulm flow murmur of ASD
• Late systolic: MVP, papillary muscle dysfunction (IHD, HOCM)
• Early diastolic: AR, PR
• Mid-diastolic: MS, TS, atrial myxoma, Austin Flint of AR
• Continuous: PDA, venous hum, aortopulmonary shunt
Other sounds
• Pericardial rub, mediastinal crunch (Hamman’s sign)
Reposition patient
• Left lateral position – ?tapping apex beat palpable or mid-late diastolic murmur of MS
• Sitting forward
o Recheck for thrill
o Consider dynamic auscultation
Respiratory phases – R side murmurs louder on inspiration, L on expiration.
Held deep expiration - enhances AR murmur & pericardial rub
Valsalva – murmurs of HOCM louder & MVP longer
Isometric exercise – most murmurs louder except AS & HOCM
Squatting - AS & MR louder
Posterior chest/Lungs
• Scars, deformity
• Sacral oedema
• Pleural effusion (stoney dullness)
• LVF (bilateral inspiratory creps)
• Lie flat
• Liver - ?pulsatile (TR), spleen (IE), AAA
• Ascites
• Renal arteries
• Palpate & auscultate femoral arteries
• Feel peripheral pulses – DP & PT
• Cyanosis
• Oedema – press for 5-15s: ?pitting
• Toe clubbing
• Signs of PVD - cold extremities, trophic changes, ulceration, Buerger’s test
• Xanthomata – Achilles tendon
• Calf tenderness - ?DVT
• Varicose veins:
o Trendelenburg test: elevate leg of supine patient, pressure over femorosaphenofemoral
junction, stand patient. If veins don’t fill then only SFJ
incompetence. If veins fill despite pressure then thigh or calf veins are
incompetent and perform Perthes’ test.
o Perthes’ test: Rpt Trendelenburg test but let just a little blood into veins. Then
get patient to stand up & down on tip-toe a few times. If calf veins competent then
muscle pump will reduce venous filling.
Fundi & Urine (IE)
Recent CXR
Killip Class for (left) heart failure based on examination:
• I: No evidence of heart failure
• II: Mild. Basal crackles & sysBP³90mmHg
• III: Pulmonary oedema, creps>1/3 of chest & sysBP³90mmHg
• IV: Cardiogenic shock, creps>1/3 of chest & sysBP<90mmHg

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