Begin the examination by introducing yourself to the patient, gaining consent, and washing your hands.
Observe the patient and the surroundings. Look for any medications, infusions, or medical instruments. These provide useful clues to the patient’s diagnosis.
Listen carefully for the close and snap of a prosthetic heart valve. These can sometimes be heard from the end of the bed and indicate that the patient already has a history of valvular heart disease.
Finally, look at the patient and form a general opinion about whether they look ill. Consider whether the patient is breathless at rest, cyanosed, or unconscious.
Next inspect the hands. Check capillary refill by pressing firmly on the patient’s nail bed for five seconds. Color should return to the nail bed within two seconds when the pressure is released. A delay suggests peripheral circulatory shut down or very cold hands.
Look for signs of peripheral cyanosis. A purple tinge to the skin that indicates decreased oxygenated blood in the peripheral arterial circulation.
Check for finger clubbing by assessing loss of nail bed angle. Clubbing is found in congenital heart disease and infective endocarditis.
Look in the nails for splinter hemorrhages. These are tiny red infarcts produced by emboli in infective endocarditis. Also, look for the yellow stains of cigarette smoke on the fingers. Smoking is a major cardiovascular risk factor.
Finally, look for Jane way palms. These are **** rushes on the palms and pulps of the fingers and Osler’s nodes, which are red, tender nodules on the finger pulps. These are both rare features of infective endocarditis.
palpate the radial pulse. The radial pulse can be located just medial to the styloid process of the radius. Feel the rate to determine whether the pulse is bradycardic, tachycardic, or normal. Assess the rhythm to determine whether it is sinus, irregular, or the irregularly irregular rhythm of atrial fibrillation.
Feel for a collapsing pulse. Place your fingers across the flexor tendons of the patient’s wrist and grasp tightly. You should feel a pulse against your fingers. If aortic regurgitation is present, elevation will cause the patient’s pulse to collapse.
Palpate the brachial pulse. The brachial pulse is located just medial to the biceps tendon in the antecubital fossa. Again, assess for rate and rhythm.
You may also assess blood pressure at this point.
The next step is to assess the jugular venous pressure of the patient. Rotate their head to the left and look for the inward flickering of the internal jugular vein beneath the sterno **** mastoid. If you cannot see this, elicit the hepatojugular reflux maneuver. Note that a raised JVP is indicative of right heart failure or fluid overload.
Inspect the face. Look for a corneal arcus and xanthelasma. Both of these are indicative of hypercholesterolemia.
Check the sclera for the jaundice of hemolytic anemia and inspect the mucous membranes for the pallor associated with anemia. Anemia is a common and reversible cause of high output heart failure.
Inspect the mouth, looking for central cyanosis and poor dental hygiene, associated with infective endocarditis.
Finally, assess the carotid pulses. Assess the pulse volume and the character. Look especially for the slow-rising pulse of aortic stenosis.
Begin the precordial examination by inspecting the patient’s chest. Look for sternotomy scars, chest malformations, and any obvious chest pulsations.
Feel for the apex, the apex beat is normally located in the fifth intercostal space in the mid-clavicular line. A laterally displaced apex suggests dilated cardiomyopathy. A forceful apex is consistent with the diagnosis of left ventricular hypertrophy. A tapping apex beat is indicative of mitral stenosis.
Palpate the right sternal edge for heaves. These are forceful heartbeats associated with right ventricular hypertrophy. Palpate each of the valvular surface markings for thrills. A thrill is a palpable heart murmur.
Next, auscultate the apex. Identify the first and second heart sound. You may need to palpate the carotid pulse simultaneously, the pulse upstroke corresponding to the first heart sound.
Auscultate each of the valvular areas, listening for added sounds.
Listen for specific heart murmurs. Mitral regurgitation has a pansystolic murmur heard loudest at the apex, with the radiations to the axilla.
Mitral stenosis is a mid-diastolic murmur heard loudest at the apex when the patient is lying on their left-hand side.
Aortic stenosis is an ejection systolic murmur, heard loudest at the aortic area, with radiation to the carotids.
Aortic regurgitation is an early diastolic murmur heard loudest at the left lower sternal edge with the patient sitting upright and leaning forward. There is apical radiation.
Auscultate the lungs for crackles or decreased air entry. These are important and may indicate pulmonary edema or pulmonary effusion, both associated with heart failure.
Check for sacral oedema.
To complete your examination, now some final considerations.
Perform an abdominal examination.
Check for ankle oedema.
Fundoscopy looking for Roth’s spots.
And hypertensive and diabetic retinopathy.
An ECG should be performed to identify any arrhythmias.
Finally, dip the patient’s urine looking for evidence of kidney injury. In congestive heart failure, look for raised specific gravity and raised urinary protein. These are associated with chronic renal failure.
In infective endocarditis, emboli cause renal infarctions and these produced raised urinary blood and protein.