Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Chest pain |
Acute Coronary Syndrome |
High BMI, smoker, male, older age, hypertensive.
Central crushing chest pain, associated nausea & sweating. Pain may radiate to arm or jaw. |
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Pericarditis |
Patient of any age presents with chest pain and mild fever.
Pain is sharp, central, pleuritic. Worse lying down and better sitting forward. Pericardial rub heard on chest auscultation. |
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Aortic Dissection |
Older male, high BP, known aneurysm/connective tissue disorder.
Sudden onset tearing central chest pain radiating to back. Associated SOB, weakness, LOC, neurological symptoms. Difference in pulse/BP left to right, hypotension. Examination and tests can all be normal. |
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| Shortness of breath |
Acute Left Ventricular Failure |
Patient with existing CCF, or acute MI, sepsis, arrhythmia.
Sudden onset acute shortness of breath worse lying flat. Tachycardia, tachypnoea, hypoxia, inc work of breathing. May have bibasal crackles to chest and peripheral oedema. |
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Chronic Cardiac Failure |
Underlying AF, valve disease, IHD, HTN, cardiomyopathy.
SOB on exertion, orthopnoea, PND, peripheral oedema. Raised JVP, bibasal crackles, heart murmurs. |
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| Heart murmur |
Aortic Stenosis |
Older patient, or known rheumatic heart disease.
Ejection systolic murmur aortic area radiating to carotids. May have associated SOB or lightheadedness on exertion. |
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Aortic Regurgitation |
Older patient, or known connective tissue disorder e.g.,g Marfan syndrome.
Soft early diastolic murmur at left lower sternal edge. Collapsing pulse, wide pulse pressure, CCF, displaced apex. Associated eponymous signs e.g., Corrigan, De Musset. |
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Mitral Stenosis |
Known rheumatic heart disease or infective endocarditis.
Mid diastolic, low pitch, rumbling murmur at apex, loud S1. Tapping apex beat, malar flush, AF. Stigmata of IE e.g., Janeway lesions, Osler’s nodes. |
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Mitral Regurgitation |
Older patient, rheumatic heart disease, IE, connective tissue disorder.
Pansystolic, high pitched murmur at apex radiating to axilla. Palpable thrill at apex, AF, 3rd heart sound. |
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Tricuspid Regurgitation |
Rheumatic heart disease, IE, Marfan, secondary to LV failure.
Pansystolic murmur in tricuspid area with split S2. Palpable thrill at LLSE, raised JVP, pulsatile liver, oedema. |
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Pulmonary Stenosis |
Congenital heart disease, tetralogy of Fallot.
Ejection systolic murmur in pulmonary area, split S2. Palpable thrill in pulmonary area, raised JVP, oedema. |
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Infective Endocarditis |
At risk: IV drug users, immunocompromised, structural heart disease.
Subacute onset fever, fatigue, night sweats, anorexia. New murmur, splinter haemorrhages, Janeway lesions, Osler’s nodes, finger clubbing, splenomegaly. |
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| Palpitations |
Atrial Fibrillation |
Unwell patient with sepsis if acute onset.
Underlying HTN, thyroid disease, valvular h/d, alcohol use. May be asymptomatic, SOB, palpitations, dizziness. Irregularly irregular pulse, tachycardia, heart failure. |
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Ventricular Ectopics |
Any age, may be healthy patient, may have pre-existing heart disease.
Sensation of ‘extra’ or ‘missed’ beat. |
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Heart block |
May be asymptomatic e.g., 1st degree heart block.
2nd or 3rd degree may have palpitations, dizziness, SOB. |
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| Valve replacement |
Bioprosthetic valve |
Midline sternotomy scar. | |
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Mechanical valve |
Midline sternotomy scar.
Audible click from end of bed or when auscultating. Click replaces S1 in mitral valve replacement and S2 for aortic valve. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient reclining 45° | ||
| Appropriate exposure of chest (bra on) | ||
| General Inspection | Systemic appearance (well/unwell) | |
| Body habitus | ||
| Respiratory effort/rate | ||
| Colour | ||
| Obvious scars/pacemaker | ||
| Audible sounds | ||
| Oedema | ||
| Clues in bed-space | ||
| Hands | Colour | |
| Temperature | ||
| Capillary refill | ||
| Tendon xanthomata | ||
| Finger clubbing | ||
| Nail changes | ||
| Peripheral stigmata | ||
| Arms | Bruising | |
| Track marks | ||
| Radial pulse | ||
| Radio-radial delay | ||
| Collapsing pulse | ||
| Brachial pulse | ||
| Blood pressure | ||
| Neck | JVP | |
| Offer hepatojugular reflux test | ||
| Auscultate carotid pulse | ||
| Palpate carotid pulse | ||
| Face | Colour | |
| Eyes | Conjunctival pallor | |
| Xanthelasma | ||
| Corneal arcus | ||
| Mouth | Central cyanosis | |
| Dentition | ||
| Chest Inspection | Fully expose chest (bra off, consider chaperone) | |
| Chest wall deformity | ||
| Scars | ||
| Pacemaker | ||
| Visible pulsation | ||
| Chest Palpation | Apex beat | |
| Parasternal heave | ||
| Thrills (all 4 areas) | ||
| Chest Auscultation
B=Bell D=Diaphragm |
Palpation of pulse | |
| Aortic area (D) | ||
| Radiation to carotids (D) | ||
| Accentuation at lower left sternal edge (D) | ||
| Pulmonary area (D) | ||
| Tricuspid area (D) | ||
| Mitral area (B, D) | ||
| Radiation to axilla (D) | ||
| Accentuation at apex (B) | ||
| Erb’s point | ||
| Back | Auscultate lung bases | |
| Sacral oedema | ||
| Legs | Scars | |
| Pedal oedema | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your cardiovascular system. This involves looking at your arms, face and chest and listening to your heart. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclined on the examination couch at 45°.
Ask the patient to expose their chest (e.g., removing shirt).
If the patient is wearing a bra, keep it on for the initial part of the examination, and ask the patient to remove it at the point of the Chest Inspection part of the examination. You may wish to consider using a chaperone in this instance.
General Inspection
Look at the patient and around the bed-space for useful signs:
- Systemic appearance (e.g., do they look unwell?)
- Body habitus (e.g., overweight or underweight)
- Respiratory effort and rate (e.g., breathlessness; possible cardiac causes include acute and chronic heart failure)
- Obvious scars or pacemakers visible from the end of the bed
- Audible sounds (e.g., from metallic heart valve)
- Oedema
- Clues around the bed-space (e.g., oxygen, IV line, GTN spray)
Hands
Examine both hands together noting:
- Temperature (e.g., cold hands indicate poor peripheral perfusion)
- Colour (e.g., pale/mottled indicate poor peripheral perfusion, blue tinge to fingertips in peripheral cyanosis, tar-staining)
- Capillary refill time of fingertip; if delayed >2 seconds then assess centrally at the sternum
- Tendon xanthomata – may indicate hypercholesterolaemia
- Finger clubbing
- Nail changes (e.g., leuconychia, koilonychia)
- Peripheral stigmata of infective endocarditis (e.g., Janeway lesions, Osler’s nodes, splinter haemorrhages)
Arms
Inspect the general appearance of the arms (e.g., any bruising, needle marks) and then assess pulses at the wrist:
- Radial pulse
- Radio-radial delay
- Collapsing pulse
- Slow rising pulse
When palpating the radial pulse, the rate (beats per minute) , rhythm (regular or irregular), character (e.g., slow rising) and volume (bounding, thready) of the pulse should be assessed. Assess for radio–radial delay by palpating both right and left radial pulses at the same time and feeling for a synchronous pulse. A delay is abnormal and may indicate aortic coarctation or dissection.
A collapsing pulse is felt by the doctor placing their hand around the patient’s wrist, excluding shoulder pain and then quickly lifting the patients extended arm above their head. A collapsing pulse is felt as an impulse against the doctor’s hand and if present may indicate aortic regurgitation. A slow-rising pulse will take time to reach its peak and the amplitude is reduced; if present a slow rising pulse may indicate aortic stenosis.
Offer to check:
- Brachial pulse
- Blood pressure
Neck
Examine the neck for:
- Carotid pulse
- Jugular Venous Pressure
Always assess carotid pulse one side at a time, never both sides at the same time. Assess the carotid pulse by first auscultating for bruits then palpating the pulse (character, volume). If bruits are present do not palpate the carotids due to increased stroke risk.
Examine the JVP by asking the patient to relax their head against the couch and turn their neck 45° to the left. Look for a visible double-pulsation of the internal jugular vein on the left side of the neck. Measure the distance of this pulsation above the sternal angle; >3-4 cm is a raised JVP and is an abnormal finding and may indicate right heart failure, fluid overload or pulmonary hypertension
Offer to perform the hepatojugular reflux test, which demonstrates how pressure on the liver increases the height of the JVP due to an increase in venous return. Check for RUQ pain, then press over the liver and observe the JVP. A normal result is a rise in JVP with pressure and a fall when pressure is released. If the JVP remains raised after pressure is released, this is abnormal and indicates right–sided heart failure and fluid volume overload.
Face
Examine the patient’s face to assess the colour and presence of:
- Flushing
- Pallor
- Central cyanosis
Eyes
Look at the patient’s eyes examining for:
- Xanthelasma indicating hyperlipidaemia
- Corneal arcus indicating hyperlipidaemia
- Conjunctival pallor indicating anaemia
Mouth
Examine inside the mouth to inspect the dentition and for any central cyanosis of the tongue
Chest Inspection
If the patient is wearing a bra, at this point ask them to remove it and consider a chaperone.
Fully expose the chest and perform a closer inspection, looking for:
- Chest wall deformities (e.g., pectus carinatum)
- Scars (e.g., midline sternotomy scar from past cardiac surgery)
- Implanted devices (e.g., pacemaker, ICD)
- Visible pulsations (e.g., apex beat)
Chest Palpation
Examine for:
- Apex beat
- Parasternal heave
- Palpable thrills
Locate and palpate the apex beat, noting its position and character. It is normally located in the mitral area, i.e. in the 5th intercostal space, mid-clavicular line. Locate this area by counting down the ribs from the 2nd rib (level of the sternal angle) to the 5th intercostal space (space between the 5th and 6th ribs) and moving across to where this level intersects the vertical mid-clavicular line. The apex beat may be displaced (i.e moved away from the normal location) due to conditions including cardiomegaly or non-palpable, for example due to an obstructive layer between the heart and the doctor’s hand (e.g., fat, air, fluid).
Palpate for a parasternal heave (with the heel of the hand) over the left lower sternal edge. If a heave is present, the doctor’s hand is lifted off the chest wall and indicates ventricular hypertrophy
Thrills are palpable murmurs. Palpate for thrills by feeling in the aortic, pulmonary, tricuspid and mitral areas using tips of fingers.
Chest Auscultation
Examine the heart sounds by listening over all four valve areas with the stethoscope. Palpate the patient’s pulse at the same time, so S1 (on the pulse, systole) and S2 (diastole) can be identified. Normal heart sounds are S1 followed by S2 with no added sounds.
High pitched sounds should be auscultated with the diaphragm of the stethoscope (D) and low pitched sounds should be auscultated with the bell of the stethoscope (B). Most murmurs are heard with the diaphragm, the main low pitched murmur of note is mitral stenosis, so the bell is only generally used to listen at the apex.
The areas to auscultate are as follows:
- Aortic (D) – 2nd intercostal space, right sternal border
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- Check for radiation to the carotid arteries by asking the patient to hold their breath in expiration. Listen over each carotid artery in turn (D)
- Aortic murmurs can be accentuated by asking the patient to lean forward and hold their breath in expiration, listening at the left lower sternal edge (D)
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- Pulmonary (D) – 2nd intercostal space, left sternal border
- Tricuspid (D) – 5th intercostal space, left sternal border
- Mitral (apex) (B, D) – 5th intercostal space, mid-clavicular line
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- Check for radiation to axilla (D)
- Mitral stenosis can be accentuated by asking the patient to tun onto their left side and hold their breath in expiration, listening at the apex (B)
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- Erb’s point (D) – 3rd intercostal space, left sternal border (to hear S1/2 clearly)
Back
Examine for the presence of:
- Pulmonary oedema by auscultating the lung bases for bi-basal crackles
- Sacral oedema by palpating the lower back for any evidence of pitting oedema
Legs
Examine the legs for:
- Pedal oedema by examining the calves and ankles for any pitting oedema
- Scars (e.g., saphenous vein harvest for CABG)
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the cardiovascular examination findings you may wish to carry out further investigations including ECG, chest X-ray or blood tests.
[*Illustrations – coming 2025]
Last updated Dec 2024
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