Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself with name and role
• Confirm the patient’s name and date of birth
• Explain what you are going to do and obtain consent

Example wording:

“I’ve been asked to examine your cardiovascular system. This means I’ll look at your arms, face and chest, and listen to your heart. You can ask me to stop at any point. Is that okay?”

Position the patient at 45° on the couch.

Ask them to expose their chest (e.g., remove shirt). If they are wearing a bra, keep it on initially and only ask them to remove it at Chest Inspection. Consider a chaperone if appropriate.

General Inspection

From the end of the bed, observe the patient and the surrounding area for relevant signs:

• Whether they appear generally well or unwell
• Body build (e.g., overweight/underweight)
• Respiratory rate and effort (breathlessness may relate to acute or chronic heart failure)
• Visible pacemaker or scars
• Audible sounds (e.g., clicking from a metallic valve)
• Oedema
• Bed-space clues such as oxygen, IV lines, or GTN spray

Hands

Look at both hands together, assessing:

• Temperature (cool peripheries can suggest poor perfusion)
• Colour (pallor/mottling suggesting poor perfusion; peripheral cyanosis; tar staining)
• Capillary refill at a fingertip; if >2 seconds, reassess centrally at the sternum
• Tendon xanthomata (suggestive of hypercholesterolaemia)
• Clubbing
• Nail changes (e.g., leuconychia, koilonychia)
• Peripheral stigmata of infective endocarditis (Janeway lesions, Osler’s nodes, splinter haemorrhages)

Arms

Inspect for bruising or needle marks and then assess pulses:

• Radial pulse
• Radio-radial delay
• Collapsing pulse
• Slow-rising pulse

When feeling the radial pulse, assess rate, rhythm, character, and volume.

Radio-radial delay is checked by palpating both radial pulses simultaneously; any delay is abnormal and can suggest aortic coarctation or aortic dissection.

A collapsing pulse is assessed by holding the wrist, ensuring no shoulder pain, and rapidly elevating the patient’s extended arm above their head; a collapsing pulse may indicate aortic regurgitation.

A slow-rising pulse rises slowly to a reduced peak and may indicate aortic stenosis.

Offer to check:

• Brachial pulse
• Blood pressure

Neck

Assess:

• Carotid pulse
• Jugular venous pressure (JVP)

Always examine carotids one side at a time. First auscultate for bruits, then palpate for pulse character and volume. If a bruit is present, do not palpate due to increased stroke risk.

To assess JVP, ask the patient to relax and turn their head about 45° to the left. Look for a double pulsation of the internal jugular vein and measure height above the sternal angle. A JVP >3–4 cm is raised and may indicate right heart failure, fluid overload, or pulmonary hypertension.

Offer the hepatojugular reflux test: check for RUQ pain, press over the liver, and observe the JVP. A normal response is a temporary rise during pressure that falls when pressure is released. Persistent elevation suggests right-sided heart failure and volume overload.

Face, Eyes, Mouth

Face: assess colour and look for flushing, pallor, and central cyanosis.
Eyes: check for xanthelasma and corneal arcus (hyperlipidaemia), and conjunctival pallor (anaemia).
Mouth: inspect dentition and look for central cyanosis of the tongue.

Chest Inspection

If a bra is being worn, ask the patient to remove it now and consider a chaperone.

Fully expose the chest and look for:

• Chest wall deformities (e.g., pectus carinatum)
• Scars (e.g., midline sternotomy scar from previous cardiac surgery)
• Devices (pacemaker, ICD)
• Visible pulsations (e.g., apex beat)

Chest Palpation

Assess for:

• Apex beat
• Parasternal heave
• Thrills

Find the apex beat (normally at the mitral area: 5th intercostal space, mid-clavicular line). Use the sternal angle at the 2nd rib as a landmark to count down to the 5th intercostal space. The apex beat may be displaced (e.g., cardiomegaly) or not palpable (e.g., due to fat, air, or fluid).

Check for a parasternal heave by placing the heel of your hand at the left lower sternal edge—a heave suggests ventricular hypertrophy.

Palpate for thrills (palpable murmurs) in the aortic, pulmonary, tricuspid, and mitral areas using the fingertips.

Chest Auscultation

Listen over all four valve areas while palpating the pulse to identify S1 (systole) and S2 (diastole). Normal heart sounds are S1 followed by S2 without added sounds.

Use the diaphragm for high-pitched sounds and the bell for low-pitched sounds. Most murmurs are heard with the diaphragm; the key low-pitched murmur is mitral stenosis, typically best with the bell at the apex.

Auscultation points:

• Aortic (D): 2nd intercostal space, right sternal border
• Check carotid radiation: ask the patient to hold their breath at end-expiration; listen over each carotid (D)
• Aortic murmurs may be accentuated with the patient leaning forward and holding breath in expiration, listening at the LLSE (D)
• 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
  • Check axillary radiation (D)
  • Mitral stenosis accentuation: roll the patient onto the left side and ask them to hold breath in expiration; listen at the apex (B)
• Erb’s point (D): 3rd intercostal space, left sternal border (helps hear S1/S2 clearly)

Back

Check for:

• Pulmonary oedema by listening for bibasal crackles
• Sacral oedema by palpating the lower back for pitting

Legs

Assess:

• Pedal oedema at ankles/calves
• Scars (e.g., saphenous vein harvesting from CABG)

Finishing

Thank the patient, allow them to cover up, and wash your hands.

Depending on findings, you may arrange further tests such as ECG, chest X-ray, and blood tests.

Last updated Dec 2024