This examination is a particularly important skill to master but is also one of the more complex ones. It not only involves a thorough examination of the heart, but also of the hands, face, neck and other areas of the body.
A chaperone should be present for this procedure.
Introduce yourself to the patient and explain the examination procedure. Ensure that you gain their consent before continuing and don't forget to wash your hands.
Ask the patient to remove their top so that the chest is entirely exposed and place them on the bed with their trunk at 45 degrees.
Begin by observing the patient from the end of the bed.
You should note whether the patient looks comfortable.
- Are they cyanosed or flushed?
- Is their respiration rate normal?
- Are there any clues around the bed such as PCA machines, GTN sprays or an oxygen mask?
Comments should be provided to the examiner on each of these areas.
Take the radial pulse. It is not a suitable pulse for describing the character of the pulsation, but can be used to assess the rate and rhythm. At this point you should also check for a collapsing pulse - a sign of aortic incompetence.
Remembering to check that the patient doesn't have any problems with their shoulder, locate the radial pulse and place your palm over it, then raise the arm above the patient's head. A collapsing pulse will present as a knocking on your palm.
Examine the extensor aspect of the elbow for any evidence of xanthomata.
At this point you should say to the examiner that you would like to take the blood pressure. They will usually tell you not to and give you the value.
Move to the patient's neck to assess their jugular venous pressure (JVP).
Ask them to turn their head to look away from you. Look across the neck between the two heads of sternocleidomastoid for a pulsation. If you do see a pulsation you need to determine whether it is the JVP - if it is then the pulsation is non-palpable, obliterable by compressing distal to it, and will be exaggerated by performing the hepatojugular reflex.
Having warned the patient that it may cause some discomfort, press down on the liver. This will cause the JVP to rise further. If you decide the pulsation is due to the JVP, note its vertical height above the sternal angle.
Move the examination to the chest, or precordium*. Start by inspecting the area, particularly looking for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well.
*In some courses, precordium is spelt "praecordium".
Palpation of the precordium starts by trying to locate the apex beat. Start by doing this with your entire hand and gradually become more specific until it is felt under one finger and describe its location anatomically.
The normal location is in the 5th intercostal space in the mid-clavicular line. However, it is not uncommon to not feel the apex beat at all.
Auscultation is now performed for all four valves of the heart in the following areas:
- Mitral valve - where the apex beat was felt.
- Tricuspid valve - on the left edge of the sternum in the 4th intercostal space.
- Pulmonary valve - on the left edge of the sternum in the 2nd intercostal space.
- Aortic valve - on the right edge of the sternum in the 2nd intercostal space.
You should listen initially with the diaphragm noting how many heart sounds you can hear:
- Are there any extra to the two normal sounds?
- Are there any murmurs?
- Are the heart sounds normal in character?
- Can you hear any rub?
If you hear any abnormal sounds you should describe them by when they occur and the type of sound they are producing. Feeling the radial pulse at the same time can give good indication as to when the sound occurs ‚Äì the pulse occurs at systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery.
You may also wish to listen with the bell of your stethoscope for any low pitched murmurs.
To further check for mitral stenosis you can lay the patient on their left side, ask them to breathe in, then out and hold it out and listen over the apex and axilla with the bell of the stethoscope.
Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the breathe in, out and hold exercise and listen over the aortic area with the diaphragm.
Finally you should assess for any oedema. Whilst the patient is sat forward, feel the sacrum for oedema and also assess the ankles for the same.
Thank the patient and allow them to dress. Report your findings to your examiner.