Like all clinical examinations, examination of the cardiovascular system begins with a general examination. This particularly involves inspection and so getting the patient in the right position to begin with is of paramount importance. The patient should be lying at 45 degrees, in a comfortable position with their hands by their side. Having introduced yourself and made sure that the patient is happy to carry on (and, of course, checking that the patient is willing for you to do what you're supposed to do!) then you can proceed with the examination.
As always, inspection requires that you take a good overall look at the patient, check they're not hooked up to any tubes or wires, and that they're looking the right colour. In fact inspection will go throughout the examination, but this is a good opportunity to get an overall impression. Does the patient look well or in pain? You can often pick up some really useful hints just by looking at the patient.
When we start looking at specific parts of the body, we begin with the hands. There's all sorts of signs which we can pick up here including peripheral cyanosis. You might also notice that a patient is anaemic if their hands are paler than you'd expect.
The fingers also tell a lot - you might see clubbing, splinter haemorrhages, Osler's nodes or Janeway lesions. Capillary nailbed pulsation is also a useful thing to pick up.
Slowly working your way up the arm, the next port of call is the radial pulse. This is one of the easier pulses to find but can be hard if you're not used to it. When you're first getting used to locating it, it's worth knowing that you can find it in the gap on the lateral (thumb) side of the muscles which run down the forearm, at the end of the arm before you get to the hand.
It's actually easier to feel the pulse if the patient has their wrist facing downwards, so that the radial artery actually 'falls' onto your fingers as you're taking the pulse. You still need to push it lightly against the bone, but it does make it a bit easier to feel - and it makes you look more likely a professional!!
As with all pulses, you want to be looking into rate, rhythm, volume and character. With the radial pulse it's a bit more difficult to think that much about character (it can be hard even with the strongest of pulses!) but you can look out for a collapsing pulse, which is a sign of aortic regurgitation. Firstly hold the pulse with the fingers of one hand, and wrap the fingers of your other hand around the forearm (particularly the anterior aspect). Then, having checked that the patient has no pain in their arm or shoulder, lift the forearm into the air so that it is pointing to the ceiling and above the height of the shoulder. If the patient does indeed have a collapsing pulse, your fingers which are around the forearm should feel the muscles contracting in a pulsatile manner, and the pulse will snake up and down your fingers (in a 'collapsing' manner).
Next we're on to the brachial pulse, and you want to see similar things to before. The blood pressure should also be measured (although in an examination situation they'll probably give you the result) at this point, and it can give you clues - if the difference between the systolic and diastolic pressures is low (a 'narrow pulse pressure'), that might indicate that there's aortic stenosis. If, on the other hand, the diastolic pressure is really low, this might be a sign of severe aortic regurgitation.
As we move round in a logical fashion, we can either look at the head and then the neck, or the neck and then the head. I think it's easier to do the head and then work your way to the chest via the neck, so we'll go to the head first.
There's a few things to see in the face when doing a cardiovascular examination. A corneal arcus (a kind of pale ring in the iris) and xantholasma (a kind of build up on the skin around the medial aspect of the eye) are both signs of chronically high cholesterol. It's also worth pulling down the lower eyelids to see if the conjunctiva are paler than usual (indicating anaemia); remember to tell your patient before doing this!
Getting the patient to open their mouth allows you to see a couple of key things. Central cyanosis (which is invariably more serious than peripheral cyanosis) can be picked up by looking at the top and bottom of the tongue. Dental hygiene is also important, as poor dental hygiene could make you start thinking about infective endocarditis.
In the neck, we want to be looking specifically at the JVP to see if it is raised or has an abnormal waveform. We also feel for the carotid pulse - a 'central pulse', and therefore useful for thinking more seriously about pulse character, as well as the standard rate, rhythm and volume. The last thing before we get to the thorax is checking the position of the trachea; it should be in the midline, and this can be checked for by pushing two fingers into the space above the sternal notch and feeling for the trachea's position; of course, warn the patient first because this can be a little uncomfortable! If it's not in the midline, you might find it's because the patient has a pneumothorax or something like a collapsed lung.
At last we get to the precordium, the area of the chest around the heart. As always, inspection is important - particularly looking for scars over the sternum or under the left arm. Palpation should locate the apex beat, which should be on the left side in the 5th intercostal space in the midclavicular line (roughly below the nipple in a man). With the apex beat you don't just want to see if it's displaced - you also need to look at its character. Palpation doesn't end with the apex beat - you also want to check the other valve areas for thrills (palpable murmurs); do this with the ball of your hand.
Percussion is rarely used in a cardiovascular exam, but auscultation is incredibly important for listening to heart sounds - and especially watching out for murmurs. The location for the mitral valve is the same as the apex beat, although getting the patient to roll onto their left and using the bell of the stethoscope can make mitral stenosis easier to hear. The tricuspid valve is listened to in the 3rd or 4th intercostal space on the left sternal edge. Don't try to listen through the sternum! The pulmonary and aortic valves are in the second intercostal spaces on the left and right respectively. For murmurs, problems with valves in the right-heart are clearer if the patient is holding their breath in because decreased thoracic pressure causes increased venous return and therefore a greater amount of blood flow through the valves. A problem with the aortic valve is clearer if the patient is leaning forward as it brings the heart closer to the stethoscope.
While the patient is leaning forwards, its worth taking the opportunity to listen to their lung bases - i.e. the lower part of their lungs, on the back. If the patient is in heart failure you'll be able to hear basal crepitations, which is a kind of crackly noise when the patient is breathing in. These are divided into 'coarse' and 'fine' crackles.
Before you finish, it's also worth checking to see if there's any swelling of the ankles, and if so, whether this is pitting or non-pitting oedema. Pitting oedema is where the swelling stays dented when you push your finger into it for a few seconds; non-pitting obviously doesn't. Again, this may be a sign that there is some kind of heart failure, as it could show that fluid is backing up and not getting through the heart properly. However, swollen ankles with pitting oedema could be a whole range of things, and shouldn't just be assumed to be heart failure unless there are a whole range of other signs which fit!!
And you're done!