Exposure

Ask the patient to remove his/her shirt/blouse and position the patient on the bed at an angle of approximately 45° (to allow assessment of the jugular venous pressure and jugular venous pulse form). Also expose the legs and particularly ankles by rolling up trouser legs or removing trousers. Once the patient is comfortable, commence the examination. Ensure that you have washed your hands and that they are at a temperature appropriate for palpation.

General inspection – look for

1. ▪ General abnormalities, such as cachexia, pallor (anaemia), cyanosis(central or peripheral), malar flush (red cheeks associated with mitral stenosis).

2. ▪ Dyspnoea and/or tachypnoea at rest (left heart failure).

3. ▪ Gross distension of the neck veins (cardiac tamponade/SVC obstruction).

4. ▪ Scars indicating surgery. Midline sternotomy, mini-sternotomy, or lateral thoracotomy are the most common approaches. Also look for CVP line and chest drain scars.

5. ▪ Ankle oedema (right heart failure).

6. ▪ Pacemaker/implantable cardiac defibrillator.

Hands

1. ▪ Inspection – look for digital clubbing (subacute bacterial endocarditis, or cyanotic congenital heart disease), splinter haemorrhages (infective endocarditis), or peripheral cyanosis. Janeway lesions and Osler's nodes (infective endocarditis).

2. ▪ Palpation – take the patient's hand and assess the temperature(patients in heart failure are usually vasoconstricted, with the hands feeling cold); degree of sweating (in heart failure the hands may be overly sweaty owing to increased adrenaline secretion). Assess digital capillary refill.

3. ▪ Radial pulse – note rate (< 50 = bradycardia, > 100 = tachycardia) and rhythm(irregularly irregular in atrial fibrillation). Lift the patient's hand above their head and feel for a collapsing pulse (aortic regurgitation). Compare pulses in both arms if there is any suspicion of aortic arch dissection or coarctation.