Approach
- Wash hands
- Rapport
- Positioning
- 45 deg
- Exposure to waist
Surroundings
General appearance
- Dyspnoea, cachexia
- Dysmorphic features
- Marfan’s
- AR,
- Turner’s
- PS,
- Down syndrome
- AVSD
- Marfan’s
- Rheumatological disorders, e.g.
- ankylosing spondylitis
- (aortic regurgitation)
- ankylosing spondylitis
Ask for vitals
Hands
- Quinke sign
- (AR)
- Clubbing
- causes
- cardiovascular
- infective endocarditis
- cyanotic congenital heart disease
- respiratory
- carcinoma
- pulmonary fibrosis
- chronic suppurative conditions
- cystic fibrosis
- bronchiectasis
- abscess, empyema
- asbestosis, mesothelioma
- GIT
- inflammatory bowel disease
- coeliac disease
- pregnancy
- cardiovascular
- causes
- Tar
- Signs of infective endocarditis—
- splinter haemorrhages
- Other causes
- trauma
- vasculitis
- RA
- PAN
- sepsis
- haematological malignancy
- Other causes
- Oslers nodes
- Janeway lesions ( palms)
- splinter haemorrhages
- Radial pulses
- Rate / rythm / character
- —right and left
- [Collapsing pulse]
- (AR, hyperdynamic, PDA)
- [pulses alternans]
- (severe LVF)
- Delay
- [Radiofemoral delay]
- (coarctation)
- [ radio radio delay]
- (subclavian artery stenosis)
- (atherosclerosis)
- (aneurysm)
- [Radiofemoral delay]
- Rate / rythm / character
- Peripheral cyanosis
- Palmar pallor
- Palmar erythema
- ( chronic liver disease, thyrotoxicosis, pregnancy, rheumatoid arthritis, polycythaemia, leukaemia)
- Xanthomata
Blood pressure
- Pulsus paradoxus (>10mmHg drop on inspiration)
- causes
- constrictive pericarditis
- pericardial effusion
- severe asthma
- causes
- postural drop
- ( hypovolaemia, drugs, Addison’s, hypopituatary, autonomic neuropathy, idiopathic
- Narrow PP
- AS
- Wide PP
- AR
Face
- Syndromes
- Malar flush
- (mitral stenosis, pulmonary stenosis, SLE)
- SLE
- Malar flush
- Eyes
- Sclerae—
- pallor
- jaundice
- (liver congestion, haemolysis from prosthetic valve)
- Pupils—Argyll Robertson (tertiary syphilis)
- (aortic regurgitation)
- Xanthelasmata
- Sclerae—
- Mouth
- Cyanosis
- Palate (high arched—Marfan’s)
- Dentition (endocarditis risk)
Neck
- Jugular venous pressure
- JVP Height
- (right ventricular failure)
- (volume overload)
- (pericardial disease)
- (TR, TS)
- Wavesform
- [cannon a]
- (CHB)
- [Giant a waves]
- (TS, PS, pulm HT)
- [Large v (atrial filling & ventr systole)]
- (TR)
- [cannon a]
- Abdominal-jugular reflex (sustained JVP innovation for the duration of pressure)
- (decreased compliance)
- Kussmaul sign ( elevation on inspiration due to decreased right ventricular filling)
- JVP Height
- Carotids
- Pulse character
- [small vol, slow rising]
- (AS)
- [collapsing]
- (AR, PDA, hyperdynamic)
- [jerky]
- (HOCM)
- [bisferience] (slow rise + collapse)
- (AS + AR)
- [small vol, slow rising]
- Bruit
- carotid
- thyroid
- (AS)
- Pulse character
Praecordium
- Inspect
- Scars—whole chest, back
- Pacemakers
- midline
- (CABG, valve replacement)
- [thoracotomy]
- (transplant, mitral valvotomy)
- Deformity
- [Pectus excavatum]
- (Marfan)
- [Pectus excavatum]
- Apex beat
- position
- character
- [heaving]
- (pressure loaded = AS, HT)
- [thrusting]
- (volume loaded = MR)
- [dyskinetic]
- LV dys Fx ? post MI
- [double]
- (HOCM)
- [tapping]
- (MS)
- [Sustained]
- (AS)
- [heaving]
- Abnormal pulsations
- Scars—whole chest, back
- Palpate
- Apex beat
- [displaced, thrusting, diffuse]
- [ severe MR, cardiomyopathy]
- [heaving, hyperdynamic]
- (AS, HT)
- [ double impulse]
- (HOCM)
- Dextrocardia?
- [displaced, thrusting, diffuse]
- Heave
- RVH
- Thrills
- [palpable P2]
- ( pulm HT)
- [palpable P2]
- Abnormal impulses
- Note: beware of dextrocardia
- Apex beat
- Auscultate
- Heart sounds
- S1
- [loud]
- (MS, tachycardia, short AV conduction)
- [soft]
- (MR, 1st HB, LBBB)
- [split]
- (RBBB)
- [loud]
- S2
- Splitting of S2:
- Increased: inspiration & RV emptying
(1) (RBBB, PS, VSD, MR) - Fixed:
(1) (ASD) - Reversed:
(1) delayed depolarization LV
(a) LBBB
(2) delayed LV emptying
(a) AS, coarc
(3) LV early filling
(a) large PDA
- Increased: inspiration & RV emptying
- [Loud]
- (HT, congenital AS, pulm HT)
- [Soft S2]
- (Calcified AV, AR)
- Splitting of S2:
- S3:
- Mid-diastolic gallop rhythm. Rapid diastolic filling. Maybe normal in children/young adults.
- Louder LSE
(1) (RVF, constrictive pericarditis) - apex
(1) (LVF, AR, MR)
- Louder LSE
- Mid-diastolic gallop rhythm. Rapid diastolic filling. Maybe normal in children/young adults.
- S4:
- Late diastolic gallop rhythm. ↓Ventricular compliance.
- LV S4
(1) (AS, MR, HT, IHD, elderly), - RV S4
(1) (pulm HT, PS)
- LV S4
- Late diastolic gallop rhythm. ↓Ventricular compliance.
- 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
- S1
- Murmurs
- Precordium
- Neck
- Loudness – soft versus loud
- Prosthetic valve sounds
- Heart sounds
Position patient
- Left lateral position
- Sitting forwards (forced expiratory apnoea)
- NB: Palpate for thrills again after positioning
- 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
- Respiratory phases
- Carotids
Back (sitting forwards)
- Scars, deformity
- Sacral oedema
- Pleural effusion (percuss)
- Left ventricular failure (auscultate)
Abdomen (lying flat—1 pillow only)
- Bruising
- LMWI
- Palpate
- liver (pulsatile etc.),
- spleen,
- aorta
- Percuss for ascites (right heart failure)
- Femoral arteries—palpate, auscultate
Legs
- Peripheral pulses
- Peripheral vascular disease
- Cyanosis, cold limbs, trophic changes, ulceration
- Oedema
- Pitting
- Bilateral
- Cardiac
- CCF, pericarditis
- Renal
- Nephrotic
- Hepatic
- Hypoalb
- Cardiac
- Unilateral
- Venous obstruction / DVT, tumor
- Bilateral
- Pitting
- Xanthomata
- Calf
- tenderness
- swelling
Other
- Temperature chart (endocarditis)
- Fundi
- [Roth spots]
- (endocarditis)
- HT
- DM
- [Roth spots]
- Urine analysis (infective endocarditis)
- Postural BP
- ECG
- CXR
- Echo
Wash hands
if you hear nothing
- MS
- roll to left, exhale
- second heart sounds
- fixed splitting = ASD
- pulm HT
- RV heave, loud S2
- pericarditis
- recheck JVP
- TR
- recheck JVP
- check liver