Cardiovascular examination and how to present it

• A cardiovascular examination answers five questions in order: how the patient looks, how fast and regularly the heart beats, whether the neck veins are raised, whether the heart is enlarged or leaking, and whether the lungs, liver and legs are congested.
• The order is fixed so that nothing is missed, and the findings are presented with the most abnormal one first, the negatives that exclude each likely diagnosis next, and a one-line summary at the end.
• Every step is inspection first, then palpation, then auscultation; you compare sides; you note what is not present as well as what is.
• The examination does not replace the electrocardiogram or echocardiography, but it tells you which to order and how quickly.
• A second page, the cardiac physical examination, covers heart sounds, murmurs and manoeuvres in depth; this page covers the whole bedside sequence and how to say it aloud.

By the end of this page you should be able to:

1. Prepare and introduce a cardiovascular examination and obtain consent.
2. Perform the examination in the usual bedside order and say what each step is looking for.
3. Recognise the important normal and abnormal signs of the hands, pulse, blood pressure, jugular venous pressure, face, precordium, auscultation areas, carotids, lung bases, abdomen and legs.
4. Present the same set of findings aloud and in written notes, with the most important finding first.
5. Give an example report for a normal examination and for atrial fibrillation, aortic stenosis and heart failure.

This page teaches the cardiovascular examination as a sequence, not a collection of signs. Most medical students can name the signs; far fewer can put them in order, say why each is checked, and turn a page of findings into a clean verbal presentation. Both skills are tested, and both matter at the bedside, because a disorganised examination misses the diagnosis and a disorganised presentation confuses the listener.

The setting is a bed or couch that can be raised to about 45 degrees, in a warm, quiet, well-lit room. You need a stethoscope with a diaphragm and a bell, a sphygmomanometer with cuffs of several sizes, a watch with a second hand, a light for the neck veins (tangential light), a ruler and straight edge for the jugular venous pressure (JVP), hand gel, gloves and a chaperone. Write or type as you go; memory is unreliable.

This page links to, but does not repeat, the companion page cardiac physical examination (cardiac-physical-examination), which covers heart sounds, murmurs, splitting and dynamic manoeuvres in depth. The repeated detail below is limited to what a presentation requires.

Introduce yourself, confirm the patient's identity, explain what you are going to do in plain words ("I am going to examine your heart and circulation, which means looking, feeling your pulse and blood pressure, feeling your chest, listening to your heart and checking your ankles"), and ask for permission. Tell the patient they may stop the examination at any time, and tell them if they need to breathe out or lie still.

Obtain consent for both the examination and, if relevant, a chaperone. Offer a chaperone to every patient, of any sex, for a chest examination; many institutions require one when the examiner and patient are of different sexes. Document the chaperone's name or "offered and declined" in the notes.

Clean your hands and the stethoscope before and after. Check the sphygmomanometer: a device with a faulty valve or a leaking bladder will mislead you more neatly than any error of judgement.

Expose the chest to the waist, with the patient covered and warmed elsewhere. For women, keep the right level of coverage that still lets you see the whole precordium and feel the apex. The usual position is reclining at about 30 to 45 degrees, with you standing on the patient's right. ^[1] You will move the patient later: left lateral for the apex and mitral area, and sitting forward for aortic regurgitation.

Before touching the patient, look for breathlessness at rest, cyanosis, cachexia and fluid overload. A 10-second look at the patient and the bed (pillows, sputum pot, inhalers, medication and fluid balance chart) often gives the diagnosis before you start.

Do the same order every time. The sequence below moves from the periphery inward and ends with the signs of congestion. Variation is allowed only when a step is genuinely impossible (for example, a patient who cannot lie flat).

Count the respiratory rate yourself; do not copy the monitor. Note the use of accessory muscles, orthopnoea (number of pillows), and any oxygen or ventilatory support. Measure temperature and pulse oximetry; an oxygen saturation below 95% suggests hypoxaemia. ^[1] Weigh the patient if heart failure is possible: a gain of fluid shows here before it shows in the ankles.

Look and feel. Clubbing is enlargement of the terminal phalanges with loss of the angle at the nail base. Splinter haemorrhages are linear subungual haemorrhages; a single one is common and trivial, several in a feverish patient with a murmur are not. Osler nodes are painful red nodules on the finger pulps; Janeway lesions are painless flat haemorrhagic spots on the palms or soles. Feel temperature and capillary refill; cold, poorly perfused hands follow low output.

Feel the radial pulse and count the rate for a full 60 seconds whenever the rhythm is irregular. ^[1] Record rate, rhythm, volume and character, and note whether the pulse correlates with the heart rate you hear at the apex (a pulse deficit, where not every beat produces a palpable wave, points to atrial fibrillation). ^[5]

Compare both radials: a difference between arms that is larger than usual suggests arterial disease. Feel the carotid pulse for the shape of the wave (the carotid is closer to the aorta, so the waveform is least distorted there), and feel the right and left carotids one at a time, never both together.

Measure in both arms. Seat the patient in a chair with the back supported, feet on the floor, the arm supported at heart level, and no clothing over the cuff, after at least 5 minutes of rest and 30 minutes without exercise, caffeine or tobacco. ^{[1] [7]} The cuff bladder should encircle about 80% of the limb and be about 40% as wide as the limb is round; using the wrong-sized cuff is one of the commonest sources of error. ^[1] Systolic pressure is the first sound heard as the column falls; diastolic is where the sound disappears.

Measure the legs as well when coarctation or peripheral arterial disease is possible; the femoral pulses should be compared with the radial by palpating both together (radio-femoral delay). ^[6]

If the patient is dizzy on standing, measure blood pressure and heart rate lying or sitting and again standing, with a 1-minute interval between changes; a fall in systolic pressure of more than 20 mmHg or diastolic pressure of more than 10 mmHg within 3 minutes is orthostatic hypotension, and an increase in heart rate on standing of 30 beats per minute or more also has meaning. ^[1]

Measure with the patient reclining at about 45 degrees, head turned slightly away, neck muscles relaxed, and tangential light. ^[1] Identify the internal jugular pulsation by its double flicker, its disappearance when you press at the base of the neck, and its change with position and breathing. Find the top of the column and measure the vertical height above the sternal notch; the upper limit of normal is 4 cm above the sternal notch. ^[1]

Ask for hepatojugular (abdominojugular) reflux: press firmly over the abdomen while the patient breathes normally, and watch the column. A rise that persists beyond a few seconds and a fall of more than 3 cm on release is abnormal. ^[1] A JVP that rises on inspiration is Kussmaul sign. ^[1]

Look for central (tongue and mucous membranes) versus peripheral cyanosis, conjunctival pallor (anaemia), jaundice, and cushingoid or marfanoid features. Note xanthelasma and corneal arcus, which in a younger patient point to dyslipidaemia and accelerated atherosclerosis.

Inspect for scars (sternotomy, thoracotomy), a pacemaker, chest wall deformity and any visible impulse. Then palpate with the patient at about 30 to 45 degrees, approaching from the right.

• Apex beat. Normally between the fourth and fifth intercostal space, just medial to the mid-clavicular line, and small. A displaced and diffuse apex means a dilated ventricle; a sustained heaving thrust means left ventricular hypertrophy. ^[1]
• Parasternal heave (a lift to the left of the sternum) suggests right ventricular hypertrophy or dilation. ^[1]
• Thrills are palpable murmurs: base right second space in systole suggests aortic stenosis; apex mitral regurgitation; left second space pulmonary stenosis; left fourth space a small muscular ventricular septal defect. ^[1]

Start at the apex with the patient on the left side, then lie supine and move from the lower left sternal edge up through each space to the upper right sternal border, and listen in the axilla and over the carotids. Add the sitting-forward position to catch an early diastolic murmur of aortic regurgitation, and listen to the back for congestion. ^[1] Learn the sequence once and use it every time. Identify S1 and S2 and the splitting of S2, then S3 and S4, clicks and opening snap. Murmurs are timed against the cycle, then described by shape, site, radiation, loudness, pitch and quality.

Use dynamic manoeuvres to separate look-alikes. Valsalva strain (which cuts venous return) quiets the murmur of aortic stenosis and mitral regurgitation and makes the murmur of hypertrophic cardiomyopathy louder; standing from a squat has a similar effect, while squatting and handgrip do the opposite. ^{[3] [4]} Right-sided murmurs get louder on inspiration; left-sided murmurs do not.

Listen and percuss at the bases for crackles, wheeze and dullness to percussion. Early inspiratory basal crackles that do not clear with coughing point to pulmonary oedema. ^[2]

Palpate for a palpable liver (a pulsatile liver points to tricuspid regurgitation), ascites (shifting dullness, fluid wave) and peripheral oedema equivalents. Significant fluid overload can produce a distended, tense, non-tender abdomen. ^[1]

Press firmly for several seconds over the shin, ankle, or sacrum in a bed-bound patient. Note the extent, symmetry, warmth, tenderness and whether the indentation persists (pitting). Pitting edema is graded 1 to 4, but the grades have no agreed definition, so describe what you saw rather than quoting a grade. ^[1] Warm, tender, unilateral swelling suggests cellulitis or thrombophlebitis; bilateral pitting swelling with a raised JVP points to fluid overload; non-pitting swelling suggests lymphatic or venous disease. ^[1] A raised JVP makes right-sided failure a likely cause; a normal JVP makes it unlikely. ^[1]

Palpate the femoral, popliteal, posterior tibial and dorsalis pedis pulses, and the brachials and radials if not already done. Compare sides. Delayed or absent femoral pulses with a radio-femoral delay point to coarctation of the aorta. ^[6]

The table collects the findings you are most likely to be asked to elicit and to name. "How to elicit" is the practical bedside action; "what it means" is the clinical inference.

A presentation has four parts in this order: the headline, the system findings, the negatives that matter, and the summary with a differential. Keep the whole examination to about one minute, because the listener is matching it to the history.

1. Headline. Start with the single most important finding, or say "the examination is unremarkable" if it is. "The most striking finding is a harsh ejection systolic murmur at the right base radiating to the carotids."
2. System findings. Go in the order you examined: general state and vitals; pulse and blood pressure; JVP; precordium; auscultation; lungs; abdomen; legs. State numbers: rate, blood pressure, JVP in centimetres, and oedema to the mid-shin or worse, rather than "some swelling".
3. Negatives that matter. Only state the negative findings that change the differential: no radio-femoral delay, no pulsus paradoxus, sinus rhythm, normal JVP, no S3, no peripheral oedema. Do not list every normal finding; silence on a normal finding is read as normal.
4. Summary and differential. End with one sentence naming what you think and what must be excluded, and one sentence on what you would do next: "In summary, this is severe aortic stenosis with left ventricular hypertrophy, not yet in heart failure; I would confirm with an echocardiogram and an electrocardiogram."

Matching written notes. Write short lines in the same order as your spoken presentation, one finding per line, with numbers: "Pulse 78/min, regular, no radio-radial delay. BP 118/74 both arms. JVP 2 cm. Apex sustained thrust, 5th ICS. Ejection systolic murmur RSB, radiates to carotids, softer with Valsalva. Lungs clear. No oedema." Do not copy prose into the notes, and do not add a diagnosis the findings do not support.

Presenting arrhythmia. An irregularly irregular pulse is the lead, named before rate: "the pulse is irregularly irregular at 92 beats per minute, with no radio-radial delay." ^[5] Then include the JVP (no a waves), the apex and whether there is any evidence of ventricular dysfunction.

Leading with the most important finding. Decide the lead by what determines management, not by what you found first. A new murmur in an febrile patient leads with fever and murmur; in a stable outpatient with breathlessness, the lead is the raised JVP and murmur together.

All patient details below are invented and illustrative; they are not real patients.

Normal examination, 28-year-old woman, pre-operative assessment. "On examination the patient is comfortable and pink, with a respiratory rate of 14. The hands are normal, with no clubbing or peripheral cyanosis. The pulse is 72 beats per minute, regular, of normal character, with no radio-radial delay. Blood pressure is 112 over 70 in both arms. The jugular venous pressure is 1 to 2 cm above the sternal notch, with no hepatojugular reflux. The face is normal. The apex beat is in the fifth intercostal space just medial to the mid-clavicular line, small and non-sustained; there is no parasternal heave or thrill. Heart sounds 1 and 2 are normal, with no added sounds and no murmur; the murmur does not change with respiration. The lung fields are clear, the abdomen is soft with no hepatic enlargement or ascites, and there is no peripheral oedema. The femoral and foot pulses are symmetrical. In summary, the cardiovascular examination is normal."

Atrial fibrillation, 71-year-old man, breathlessness. "On examination the patient is comfortable at rest but breathless on walking 20 metres. The pulse is irregularly irregular at 104 beats per minute, of normal volume, with no radio-radial delay. Blood pressure is 138 over 82 in both arms. The jugular venous pressure is 3 cm with absent a waves and no cannon waves. The apex is not displaced and there is no heave. Heart sounds 1 and 2 are present and there is no added gallop; there is no murmur. The lung bases are dull to percussion on the right with reduced air entry. There is no peripheral oedema. In summary, the findings are consistent with atrial fibrillation with a rapid ventricular response, with a small right-sided effusion but no peripheral congestion; common alternatives include pneumonia and exacerbation of airways disease."

Aortic stenosis, 68-year-old man, exertional syncope. "On examination there is no central cyanosis. The hands are normal. The pulse is 74 beats per minute, regular, but small and slow rising, with no radio-radial delay. Blood pressure is 124 over 78. The jugular venous pressure is 2 cm. The apex is sustained and slightly displaced. There is no parasternal heave or thrill, but a thrill is felt at the right second space. On auscultation the first heart sound is normal, the second is single, and there is a harsh crescendo-decrescendo systolic murmur at the right and left upper sternal borders radiating to both carotids, softer with Valsalva strain. The lung fields are clear and there is no oedema. In summary, this is severe aortic stenosis with a narrowed pulse, single second sound and radiation to the carotids; an echocardiogram is needed to confirm severity and guide intervention."

Heart failure, 62-year-old woman, orthopnoea. "On examination the patient is breathless at rest, using two pillows, with ankle swelling. The pulse is 96 beats per minute, regular, with no radio-radial delay. Blood pressure is 156 over 92. The jugular venous pressure is 6 cm above the sternal notch with a positive hepatojugular reflux of more than 3 cm; the waveform is not further characterised. The apex is diffuse and displaced to the sixth intercostal space. There is no parasternal heave. There is a pansystolic murmur at the apex radiating to the axilla. The lung bases have bilateral crackles that do not clear with coughing and dullness at both bases. The liver is enlarged and tender. There is bilateral pitting oedema to the mid-shin, warm and symmetrical, with no erythema. In summary, this is congestive heart failure with both left- and right-sided features and functional mitral regurgitation; key alternatives are chronic lung disease and renal sodium retention, and I would confirm with natriuretic peptides, renal function and an echocardiogram."

• Reading the carotid pulse as the venous pulse, or letting the patient strain or hold their breath during hepatojugular reflux, which raises the JVP on its own.
• Measuring the JVP from the clavicle instead of the sternal notch, or not recording the patient's angle; "JVP raised" without a number is uninterpretable.
• Using the wrong cuff. A cuff one size too small overestimates the pressure and one a size too large underestimates it; measure the arm first. ^[7]
• Forgetting dynamic manoeuvres. Hypertrophic cardiomyopathy and aortic stenosis both give a systolic ejection murmur; squatting and Valsalva separate them in under a minute.
• Treating a flow murmur as aortic stenosis, or missing a soft severe stenosis in a low-flow state, where the pulse is small and the murmur is quiet.
• Stating mitral regurgitation when the murmur is at the lower sternal border. Lower sternal border means the tricuspid valve or a septal defect; mitral regurgitation is at the apex and into the axilla.
• Listing every normal finding. The listener loses the abnormal one by the fifth item.
• Presenting findings in the order found, rather than leading with the finding that determines management.
• Quoting an oedema grade without defining it, since the grades 1 to 4 have no agreed meaning; describe the extent and pitting.

• A fixed order prevents omissions: general state, hands, pulse, blood pressure, JVP, face, precordium, auscultation, lungs, abdomen, oedema, peripheral pulses.
• Blood pressure needs the right cuff (bladder 80% round, 40% wide), rest, correct posture and readings in both arms; cuff size is a common source of error.
• The JVP is measured at about 45 degrees as the vertical height above the sternal notch, with an upper limit of normal of 4 cm; hepatojugular reflux persisting beyond a few seconds or above 3 cm is abnormal, and a rise on inspiration is Kussmaul sign.
• Pulsus paradoxus is an inspiratory fall in systolic pressure of more than 10 mmHg; it is measured by slow cuff deflation.
• A displaced diffuse apex beat means a dilated left ventricle; a sustained thrust means left ventricular hypertrophy; a parasternal heave means right ventricular pressure or volume overload.
• An S3 usually signals systolic dysfunction in adults (and can be normal in children, pregnancy and to about age 40); an S4 is atrial contraction into a stiff ventricle and is absent in atrial fibrillation.
• Diastolic and continuous murmurs are always abnormal; a soft short systolic murmur with a normal second sound in a well person is usually a flow murmur.
• Atrial fibrillation gives an irregularly irregular pulse, loss of a waves in the JVP, no S4 and a possible pulse deficit; its rapid ventricular response usually runs 140 to 160 beats per minute. ^[5]
• Aortic stenosis gives a slow small pulse, single or paradoxically split second sound, sustained apex, and a crescendo-decrescendo murmur radiating to the carotids; right-sided murmurs grow louder on inspiration, and aortic stenosis quiets with Valsalva strain while hypertrophic cardiomyopathy gets louder.
• Mitral regurgitation gives a holosystolic murmur at the apex radiating to the axilla that increases with handgrip or squatting and decreases with standing or Valsalva.
• Heart failure gives raised JVP, a diffuse displaced apex, basal crackles that do not clear with coughing, a pulsatile or enlarged liver, ascites and pitting ankle or sacral oedema; a pansystolic apex murmur can be functional mitral regurgitation.
• A normal JVP makes right-sided failure an unlikely cause of peripheral oedema.
• Present with the headline first, then system findings with numbers, then the negatives that change the differential, and end with a one-line summary.