Cardiology: History and Examination

• History: Approach to the Cardiac History | Chest Pain | Breathlessness | Palpitations | Syncope and Dizziness | Swelling and Other Symptoms | Past, Drug, Family and Social History | Grading Symptoms
• Examination: Preparing for the Examination | General Inspection | Hands | Pulse | Blood Pressure | Face, Eyes and Mouth | Jugular Venous Pressure | Precordium — Inspection and Palpation | Heart Sounds | Murmurs | Added Sounds | Lungs, Abdomen and Legs | Peripheral Vascular Examination | Completing and Presenting
• Putting it together: Signs of Heart Failure | Valve Lesions at a Glance | Signs of Endocarditis | Special Situations
• Revision: Signs at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Cardiac history and examination — most cardiac diagnoses are made, or strongly suspected, from the history. The examination then confirms the likely problem, judges how severe it is, and looks for complications such as heart failure or endocarditis. This chapter covers each symptom, a step-by-step examination, how to recognise the common valve lesions, and how to present your findings.
Your four questions for every patient: Is this cardiac, and is it dangerous right now? What is the likely cause (ischaemia, valve, rhythm, muscle, pericardium)? How severe is it — symptoms, signs of heart failure, complications? What are the risk factors and the impact on the person's life?

Approach to the Cardiac History

• Introduce yourself, confirm identity, gain consent, and ask open questions first ("Tell me what's been happening").
• Presenting complaint — in the patient's words.
• History of presenting complaint — explore each symptom (see below), then ask about the other key cardiac symptoms:
  • Chest pain or tightness.
  • Breathlessness — on exertion, lying flat (orthopnoea), waking at night (paroxysmal nocturnal dyspnoea).
  • Palpitations.
  • Dizziness, blackouts or falls.
  • Ankle swelling.
  • Fatigue and reduced exercise tolerance.
  • Calf pain on walking (claudication).
• Systems review — fever and weight loss (endocarditis), cough and haemoptysis, symptoms of thyroid disease, anaemia, stroke or TIA.
• Ideas, concerns and expectations — chest pain is frightening; ask what the patient thinks is going on.
• Summarise back to the patient and check you've understood.

💡 Clinical Pearl: For any symptom, ask "What can you do now that you could do before, and what stops you?" Exercise tolerance in real terms (stairs, distance to the shops) tells you more about severity than any scale.

Chest Pain

• Use SOCRATES — Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and relieving factors, Severity.
• Angina (cardiac ischaemia):
  • Central chest tightness, heaviness, pressure or a "band" (patients often deny "pain").
  • Radiates to the left arm, both arms, jaw, neck or back.
  • Brought on by exertion, emotion, cold or heavy meals; relieved by rest or GTN within about 5 minutes.
  • Typical angina (NICE CG95) has all three — constricting discomfort in the chest, neck, shoulders, jaw or arms; precipitated by exertion; relieved by rest or GTN within 5 minutes. Atypical — two of three. Non-anginal — one or none.
• Acute coronary syndrome — similar pain but at rest, lasting over 15 minutes, or increasing in frequency or severity (unstable angina); with sweating, nausea, breathlessness, fear. Older people, women and people with diabetes may have atypical or no pain (breathlessness, collapse, confusion).
• Other important causes:
  • Aortic dissection — sudden, tearing or ripping pain radiating to the back, maximal at onset; hypertension, Marfan syndrome.
  • Pericarditis — sharp central pain, worse lying flat and on breathing in, better sitting forward; recent viral illness.
  • Pulmonary embolism — pleuritic pain with sudden breathlessness, haemoptysis; risk factors for VTE.
  • Pneumothorax — sudden one-sided pleuritic pain and breathlessness.
  • Pneumonia — pleuritic pain, fever, productive cough.
  • Oesophageal — burning, related to meals or lying down, acid taste; oesophageal spasm can mimic angina and respond to GTN.
  • Musculoskeletal — localised, reproduced by pressing or moving; but tenderness doesn't exclude ACS.
  • Anxiety — with hyperventilation and tingling; a diagnosis of exclusion.
  • Shingles — burning dermatomal pain before the rash.

⚠️ Safety Pearl: Never let a "typical" musculoskeletal or indigestion story stop you from doing an ECG in someone with chest pain and risk factors. ACS, dissection and PE can all present atypically.

Breathlessness

• Onset and course — sudden (PE, pneumothorax, acute pulmonary oedema, arrhythmia), over days (pneumonia, decompensated heart failure), over months (chronic heart failure, valve disease, lung disease, anaemia).
• Exertional breathlessness — how far can they walk on the flat, how many stairs?
• Orthopnoea — breathless lying flat; ask "How many pillows do you sleep on, and why?" (pulmonary congestion — heart failure, but also severe COPD, obesity, diaphragm weakness).
• Paroxysmal nocturnal dyspnoea — waking from sleep gasping, needing to sit up or go to a window; fairly specific for left heart failure.
• Associated features — ankle swelling, weight gain (fluid), cough with pink frothy sputum (pulmonary oedema), wheeze ("cardiac asthma"), chest pain, palpitations, fatigue.
• Non-cardiac causes — COPD, asthma, interstitial lung disease, anaemia, obesity and deconditioning, thyroid disease, anxiety, neuromuscular disease.
• Grade it — NYHA class (see Grading Symptoms).

Palpitations

• Ask the patient to tap out the rhythm — fast and regular, fast and irregular, or "missed" or extra beats.
• Key questions:
  • How do they start and stop — suddenly (re-entrant SVT, VT) or gradually (sinus tachycardia, anxiety)?
  • How long do they last, and how often?
  • Triggers — exercise (catecholaminergic arrhythmias, VT in cardiomyopathy), caffeine, alcohol ("holiday heart" AF), stress, standing up, lying on the left side (ectopics).
  • Terminating manoeuvres — breath-holding, straining or cold water stopping them suggests SVT.
  • Associated symptoms — chest pain, breathlessness, dizziness, syncope (red flag), polyuria afterwards (atrial stretch — SVT, AF).
• Common patterns:
  • Ectopic beats — "missed beat then a thump", worse at rest and lying down; usually benign.
  • SVT — sudden onset of rapid regular palpitations in a young person, stopped by vagal manoeuvres.
  • AF — irregular, often with breathlessness or reduced exercise tolerance; older people, hypertension, alcohol, thyroid disease.
  • VT — fast palpitations with dizziness or collapse in someone with heart disease (previous MI, cardiomyopathy).
• Ask about — thyroid symptoms, anaemia, caffeine, energy drinks, alcohol, recreational drugs (cocaine, amphetamines), medicines (salbutamol, levothyroxine, QT-prolonging drugs), family history of sudden death.

Syncope and Dizziness

• Syncope is transient loss of consciousness from reduced brain blood flow, with rapid, full recovery. Get an eyewitness account — what did they look like, how long, any jerking, colour?
• Before — what were they doing (standing, exertion, turning the head, passing urine, coughing), any warning (light-headed, hot, nauseated, vision greying — vasovagal), palpitations or chest pain?
• During — pale (cardiac or vasovagal), brief jerks are common in syncope; prolonged rhythmic jerking, tongue biting (side of tongue), and cyanosis suggest a seizure.
• After — quick recovery suggests syncope; prolonged confusion suggests a seizure; injury suggests no warning (more worrying).
• Patterns:
  • Vasovagal — triggers (standing, heat, pain, blood), prodrome, young people; benign.
  • Orthostatic — on standing; drugs, dehydration, autonomic failure; older people.
  • Situational — cough, micturition, defecation, swallowing.
  • Carotid sinus hypersensitivity — turning the head, shaving, tight collar; older people.
  • Cardiac — during exertion (aortic stenosis, HCM, arrhythmias), while lying down, with palpitations or chest pain, without warning, with known heart disease or a family history of sudden death.
• Dizziness — distinguish light-headedness (presyncope — cardiovascular) from vertigo (spinning — vestibular) and unsteadiness (neurological).

⚠️ Safety Pearl: Collapse during exercise, collapse while lying down, or collapse with a family history of sudden death under 40 is cardiac until proven otherwise. Do an ECG and seek urgent cardiology advice.

Swelling and Other Symptoms

• Ankle swelling — both legs (heart failure, nephrotic syndrome, liver disease, drugs — amlodipine and other calcium channel blockers, NSAIDs, steroids, pregabalin) versus one leg (DVT, cellulitis, Baker's cyst, venous obstruction). Ask about weight gain (fluid), abdominal swelling (ascites), and swelling of the sacrum in bedbound patients.
• Fatigue — common in heart failure and on beta-blockers; also anaemia, thyroid disease, depression, sleep apnoea.
• Claudication — cramping calf, thigh or buttock pain on walking, relieved by rest within minutes; peripheral arterial disease (a marker of coronary disease). Rest pain at night relieved by hanging the leg down — critical limb ischaemia.
• Fever, sweats and weight loss — think of infective endocarditis in anyone with a murmur, prosthetic valve, device or injecting drug use.
• Cough and haemoptysis — pulmonary oedema (pink frothy sputum), mitral stenosis, PE.
• Stroke or TIA symptoms — AF, endocarditis, PFO, LV thrombus.
• Hoarse voice — rarely, an enlarged left atrium or aortic aneurysm compresses the left recurrent laryngeal nerve (Ortner's syndrome).

Past, Drug, Family and Social History

• Past medical history:
  • Previous MI, angina, stents (when, which vessel), CABG, valve surgery (mechanical or tissue valve), pacemaker or ICD, heart failure, AF, rheumatic fever in childhood, congenital heart disease.
  • Risk factors — hypertension, diabetes, high cholesterol, CKD, stroke or TIA, peripheral arterial disease.
  • Other — thyroid disease, sleep apnoea, autoimmune disease (SLE, rheumatoid arthritis), HIV, previous chemotherapy or chest radiotherapy (cardiotoxicity).
• Drug history:
  • Cardiac drugs — and adherence.
  • Anticoagulants and antiplatelets (bleeding risk, procedures).
  • Drugs that cause or worsen heart problems — NSAIDs (heart failure, hypertension), steroids, calcium channel blockers (oedema), QT-prolonging drugs, thyroxine, decongestants, anthracyclines and trastuzumab.
  • Over-the-counter and herbal products; recreational drugs (cocaine, amphetamines, anabolic steroids).
  • Allergies — including contrast and aspirin.
• Family history — premature coronary disease (a first-degree relative: men under 55, women under 65), sudden unexplained death under 40, cardiomyopathy, inherited arrhythmias, familial hypercholesterolaemia, aortic disease or dissection.
• Social history:
  • Smoking (pack-years) and vaping; alcohol (units a week); recreational drugs.
  • Diet, physical activity, weight.
  • Occupation — driving (especially bus and lorry licences — DVLA rules), pilots, work involving heights or heavy machinery.
  • Home circumstances, stairs, carers, mobility and daily activities.

Grading Symptoms

Preparing for the Examination

• WIPER:
  • Wash your hands.
  • Introduce yourself and check identity.
  • Permission (consent) and offer a chaperone.
  • Expose the chest appropriately (preserve dignity — cover when not examining).
  • Reposition — sitting at 45 degrees, head supported, neck relaxed.
• Ask about pain before touching.
• Order — end of the bed, hands, pulses and BP, face and neck (JVP, carotids), precordium (inspect, palpate, auscultate), back of the chest, abdomen if relevant, legs.

General Inspection

• From the end of the bed — comfortable or distressed; breathless at rest or when undressing; colour (pallor, central cyanosis, flushed cheeks); sweating; body habitus (obesity, cachexia — "cardiac cachexia" in advanced heart failure).
• Around the bed — oxygen, GTN spray, inhalers, fluid charts, urine bottles, mobility aids, a walking stick, IV lines, ECG monitor.
• Scars — midline sternotomy (CABG or valve surgery), left lateral thoracotomy (mitral valvotomy, coarctation repair, PDA ligation), infraclavicular pacemaker or ICD scar, leg scars from vein harvest (CABG), groin or wrist puncture sites.
• Syndromic features — Marfan syndrome (tall, long limbs — aortic root dilatation, mitral prolapse), Down syndrome (AVSD), Turner syndrome (coarctation, bicuspid valve), Noonan syndrome (pulmonary stenosis).
• Audible click of a mechanical valve.

Hands

• Temperature — cool peripheries in low output states or shock; warm in high-output states.
• Capillary refill — press the nail bed for 5 seconds; normal is under 2 seconds.
• Peripheral cyanosis — blue fingers (poor perfusion, cold).
• Clubbing — loss of the nail-bed angle (Schamroth's window test): cyanotic congenital heart disease, infective endocarditis, atrial myxoma, plus lung and gut causes.
• Splinter haemorrhages — endocarditis (also trauma — more than a few is significant).
• Janeway lesions (painless red macules on the palms) and Osler's nodes (painful nodules on the finger pulps) — endocarditis.
• Tendon xanthomas (knuckles, Achilles) — familial hypercholesterolaemia.
• Nicotine staining — smoking.
• Koilonychia or pale palmar creases — anaemia.
• Arachnodactyly (long fingers) — Marfan syndrome.
• Tremor, sweaty palms — thyrotoxicosis (AF, high-output state).

Pulse

• Radial pulse — rate (count for 30 seconds, or a full minute if irregular) and rhythm:
  • Regular.
  • Regularly irregular — sinus arrhythmia (varies with breathing), second-degree heart block, regular ectopics (bigeminy).
  • Irregularly irregular — AF (or frequent ectopics). In AF the apex rate can exceed the radial rate (pulse deficit).
• Radio-radial delay or different volumes — subclavian stenosis, aortic dissection, coarctation (proximal to the left subclavian).
• Radio-femoral delay — coarctation of the aorta (check in young people with hypertension).
• Collapsing pulse — feel the radial with your palm and raise the arm (after checking for shoulder pain): a forceful tapping pulse that quickly falls away — aortic regurgitation, PDA, high-output states (anaemia, thyrotoxicosis, pregnancy, AV fistula).
• Carotid pulse — assess the character and volume (one side at a time; listen for a bruit first):
  • Slow-rising, low-volume — aortic stenosis.
  • Bisferiens (two peaks) — mixed aortic valve disease, HCM.
  • Jerky — HCM.
  • Small volume — low cardiac output, shock.
  • Bounding — CO2 retention, sepsis, high-output states.
  • Pulsus alternans — strong and weak beats alternating — severe LV failure.
  • Pulsus paradoxus — the pulse weakens on breathing in (systolic fall over 10 mmHg) — cardiac tamponade, severe asthma or COPD, constriction.

Blood Pressure

• Measure BP (both arms at first assessment); a difference over 15 mmHg is abnormal (subclavian stenosis, dissection, coarctation).
• Wide pulse pressure (systolic minus diastolic, e.g. 170/40) — aortic regurgitation, high-output states, stiff arteries in older people.
• Narrow pulse pressure — severe aortic stenosis, tamponade, low cardiac output.
• Lying and standing BP — in falls, syncope and dizziness (orthostatic hypotension: fall of 20 mmHg systolic or 10 diastolic within 3 minutes).
• Technique and thresholds are covered in the Cardiac Investigations chapter.

Face, Eyes and Mouth

• Eyes:
  • Conjunctival pallor — anaemia.
  • Xanthelasma (yellow eyelid plaques) and corneal arcus under 50 — hyperlipidaemia.
  • Conjunctival petechiae and Roth spots (retinal haemorrhages with pale centres on fundoscopy) — endocarditis.
  • Hypertensive retinopathy on fundoscopy.
  • Lens dislocation (upward) — Marfan syndrome.
• Face — malar flush (purple-red cheeks — mitral stenosis, low output), puffy face (hypothyroidism), signs of thyroid eye disease.
• Mouth — central cyanosis (blue tongue and lips — right-to-left shunt, severe lung disease), dental hygiene (endocarditis source), high-arched palate (Marfan syndrome), dehydration.

Jugular Venous Pressure

• What it shows: The pressure in the right atrium — a window on the right side of the heart and fluid status.
• How to assess:
  • Patient at 45 degrees, head turned slightly to the left, neck relaxed.
  • Look for the pulsation of the internal jugular vein between the two heads of sternocleidomastoid, rising towards the earlobe.
  • Measure the vertical height of the top of the pulsation above the sternal angle — normal is under 3–4 cm.
• Venous or arterial? The JVP:
  • Has a double waveform (two peaks per heartbeat — "a" and "v" waves).
  • Is not palpable and can be occluded by gentle pressure at the base of the neck.
  • Changes with position (rises lying flat, falls sitting up) and with breathing (falls on inspiration).
  • Rises with abdominal pressure (hepatojugular reflux — a sustained rise suggests right heart failure).
• Raised JVP — right heart failure, fluid overload, tricuspid regurgitation, PE, pulmonary hypertension, tamponade, constrictive pericarditis. Fixed, raised and non-pulsatile — superior vena cava obstruction.
• Waveform abnormalities:
  • Large "v" waves — tricuspid regurgitation (may pulse the earlobes).
  • Cannon "a" waves — atria contracting against a closed tricuspid valve: complete heart block (irregular cannon waves), VT.
  • Absent "a" waves — AF.
  • Kussmaul's sign (JVP rises on inspiration) — constrictive pericarditis, restrictive cardiomyopathy, RV infarction, tamponade (less often).
• Low JVP (not visible lying flat) — dehydration, hypovolaemia.

Precordium — Inspection and Palpation

• Inspect — scars, pacemaker or ICD box, chest wall deformity (pectus excavatum, carinatum — Marfan syndrome), visible apex pulsation.
• Apex beat — the lowest and most lateral point where the pulsation is felt; normally the 5th intercostal space, mid-clavicular line.
  • Displaced (laterally or downwards) — LV dilatation (heart failure, mitral or aortic regurgitation, dilated cardiomyopathy). Also shifted by chest wall deformity, pneumothorax, effusion or lung collapse.
  • Heaving (forceful, sustained) — pressure overload with LV hypertrophy: aortic stenosis, hypertension, HCM.
  • Thrusting (forceful, not sustained, displaced) — volume overload: aortic or mitral regurgitation.
  • Tapping — palpable first heart sound — mitral stenosis.
  • Double impulse — HCM.
  • Impalpable — obesity, emphysema, pericardial effusion, dextrocardia (check the right side).
• Parasternal heave — place the heel of your hand left of the sternum; a lift suggests RV hypertrophy (pulmonary hypertension, pulmonary stenosis, mitral stenosis) or a large left atrium.
• Thrills — palpable murmurs (grade 4 or more) — feel over each valve area with your palm. For example, aortic stenosis (aortic area), VSD (left sternal edge).

Heart Sounds

• Auscultation areas (listen with the diaphragm, then the bell):
  • Mitral — apex (5th intercostal space, mid-clavicular line).
  • Tricuspid — lower left sternal edge (4th–5th intercostal space).
  • Pulmonary — 2nd intercostal space, left sternal edge.
  • Aortic — 2nd intercostal space, right sternal edge.
• Time sounds against the carotid pulse — S1 is just before the pulse; S2 just after.
• First heart sound (S1) — closure of the mitral and tricuspid valves:
  • Loud — mitral stenosis, tachycardia, short PR.
  • Soft — mitral regurgitation, long PR, poor LV function.
  • Variable — AF, complete heart block.
• Second heart sound (S2) — closure of the aortic (A2) and pulmonary (P2) valves:
  • Soft or absent A2 — severe aortic stenosis.
  • Loud P2 — pulmonary hypertension.
  • Normal splitting — widens on inspiration.
  • Wide splitting — RBBB, pulmonary stenosis.
  • Fixed splitting (doesn't change with breathing) — ASD.
  • Reversed splitting (splits on expiration) — LBBB, severe aortic stenosis.
• Prosthetic valves — mechanical valves produce a crisp metallic click (opening and closing); loss of the click suggests valve thrombosis — an emergency.

Murmurs

• Describe a murmur systematically:
  • Timing — systolic (with the pulse) or diastolic; ejection (crescendo–decrescendo) or pansystolic.
  • Site where loudest.
  • Radiation — to the carotids (aortic stenosis), axilla (mitral regurgitation).
  • Grade (Levine, out of 6) — 1 barely audible; 2 soft; 3 moderate, no thrill; 4 loud with a thrill; 5 heard with the stethoscope edge on the chest; 6 heard with the stethoscope off the chest.
  • Pitch and quality — harsh, blowing, rumbling.
  • Effect of manoeuvres (below).
• Manoeuvres:
  • Left lateral position, breath out, listen at the apex with the bell — mitral stenosis (low-pitched mid-diastolic rumble).
  • Sitting forward, breath held in expiration, listen at the left sternal edge with the diaphragm — aortic regurgitation (early diastolic murmur).
  • Inspiration makes right-sided murmurs louder; expiration makes left-sided murmurs louder.
  • Valsalva or standing makes the murmurs of HCM and mitral valve prolapse louder (other murmurs get quieter); squatting does the opposite.
• Systolic murmurs:
  • Ejection systolic — aortic stenosis, aortic sclerosis (no radiation, normal pulse), pulmonary stenosis, HCM, ASD (flow), innocent flow murmurs (pregnancy, anaemia, fever, children).
  • Pansystolic — mitral regurgitation (apex to axilla), tricuspid regurgitation (left sternal edge, louder on inspiration, large v waves), VSD (left sternal edge, often loud with a thrill).
  • Late systolic — mitral valve prolapse (after a mid-systolic click).
• Diastolic murmurs — always pathological:
  • Early diastolic — aortic regurgitation, pulmonary regurgitation (Graham Steell murmur in pulmonary hypertension).
  • Mid-diastolic — mitral stenosis, Austin Flint murmur (severe aortic regurgitation), atrial myxoma.
• Continuous — PDA ("machinery" murmur under the left clavicle), AV fistula; venous hum in children (disappears lying down).
• Innocent murmurs — soft (grade 1–2), systolic, short, no radiation, normal heart sounds, no symptoms, normal ECG; anything else needs an echo.

Added Sounds

• Third heart sound (S3) — early diastole, low-pitched ("Ken-tuck-y"); rapid ventricular filling: heart failure, mitral regurgitation; can be normal in young people, athletes and pregnancy.
• Fourth heart sound (S4) — late diastole, before S1 ("Ten-nes-see"); atria pushing into a stiff ventricle: LVH, hypertension, aortic stenosis, HCM, acute MI. Never heard in AF (no atrial contraction).
• Gallop rhythm — S3 or S4 with tachycardia.
• Opening snap — early diastole, high-pitched, after S2 — mitral stenosis (pliable valve).
• Ejection click — early systole — bicuspid aortic valve, pulmonary stenosis.
• Mid-systolic click — mitral valve prolapse.
• Pericardial rub — scratchy, "creaking leather" sound, best sitting forward — pericarditis (may come and go).
• Pericardial knock — early diastolic — constrictive pericarditis.
• Tumour plop — rare — left atrial myxoma.

Lungs, Abdomen and Legs

• Lung bases (sit the patient forward) — fine inspiratory crackles (pulmonary oedema), dullness and reduced breath sounds (pleural effusions — often bilateral in heart failure), wheeze.
• Sacral oedema — check in people lying in bed (fluid collects at the lowest point).
• Abdomen (if relevant) — tender, enlarged liver (congestion), pulsatile liver (severe tricuspid regurgitation), ascites, splenomegaly (endocarditis), abdominal aortic aneurysm (expansile pulsatile mass), renal bruits.
• Legs:
  • Pitting oedema — press for 10 seconds; note how far up it goes (ankles, shins, knees, thighs).
  • Peripheral pulses (femoral, popliteal, posterior tibial, dorsalis pedis).
  • Vein harvest scars (CABG), varicose veins, signs of DVT, skin changes of arterial or venous disease, ulcers.

Peripheral Vascular Examination

• Inspect — colour (pale, dusky, mottled), hair loss, shiny skin, ulcers (arterial — toes, heels, punched out; venous — gaiter area), gangrene, amputations, scars from bypass surgery.
• Palpate — temperature (compare both sides), capillary refill, all pulses (radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis), abdominal aorta.
• Auscultate — bruits over the carotids, abdominal aorta, renal arteries, femoral arteries.
• Buerger's test — raise the leg: pallor at a low angle (under 20 degrees) suggests severe ischaemia; then hang it down — slow reddening ("sunset foot") confirms it.
• ABPI — ankle–brachial pressure index with a Doppler: 0.9–1.3 normal; under 0.9 peripheral arterial disease; under 0.5 severe; over 1.3 calcified arteries (diabetes, CKD).
• Acute limb ischaemia — the 6 Ps: Pain, Pallor, Pulselessness, Perishing cold, Paraesthesia, Paralysis — a vascular emergency.

Completing and Presenting

• To complete the examination, say you would:
  • Check observations (heart rate, BP lying and standing, respiratory rate, oxygen saturations, temperature).
  • Do a 12-lead ECG.
  • Fundoscopy (hypertension, endocarditis).
  • Urine dipstick (haematuria in endocarditis, proteinuria in hypertension).
  • Peripheral vascular examination if relevant.
  • Arrange tests — echo, chest X-ray, bloods (see the Cardiac Investigations chapter).
• Thank the patient, help them dress, wash your hands.
• Presenting — a clear structure:
  • "Mr X is a 72-year-old man who is comfortable at rest."
  • Positive findings first — "He has a slow-rising, low-volume pulse, a narrow pulse pressure, a heaving, undisplaced apex, and a harsh grade 3 ejection systolic murmur loudest at the aortic area radiating to the carotids, with a soft second heart sound."
  • Relevant negatives — "There are no signs of heart failure or endocarditis."
  • Summary and diagnosis — "These findings are consistent with severe aortic stenosis."
  • Differential, severity, cause and complications — "Signs of severity are... The likely cause at his age is calcific degeneration."
  • Next steps — "I would like to do an ECG and arrange an echocardiogram."

💡 Clinical Pearl: When presenting a murmur, always add the four things examiners want: the likely lesion, signs of severity, the likely cause, and any complications (heart failure, AF, endocarditis).

Signs of Heart Failure

• Left-sided (pulmonary congestion) — breathlessness, orthopnoea, PND; tachypnoea, bibasal fine crackles, pleural effusions, S3 gallop, displaced apex, pulsus alternans in severe disease.
• Right-sided (systemic congestion) — raised JVP, positive hepatojugular reflux, peripheral pitting oedema, sacral oedema, tender hepatomegaly, ascites, weight gain.
• Low output — cool peripheries, prolonged capillary refill, low BP, narrow pulse pressure, confusion, oliguria.
• Look for the cause — previous MI (scars, Q waves), valve disease (murmur), AF, hypertension, alcohol, thyroid disease, cardiomyopathy.
• Warm/cold and wet/dry — a quick bedside way to classify acute heart failure: "warm and wet" (congested, perfused — diuretics), "cold and wet" (congested, poorly perfused — cardiogenic shock).

Valve Lesions at a Glance

Signs of Endocarditis

• Suspect in anyone with fever and a murmur (new or changed), especially with a prosthetic valve, device, previous endocarditis, congenital heart disease or injecting drug use.
• Signs:
  • Fever, malaise, weight loss.
  • Murmur — new regurgitant murmur (valve destruction).
  • Hands — splinter haemorrhages, Janeway lesions, Osler's nodes, clubbing (subacute).
  • Eyes — conjunctival petechiae, Roth spots.
  • Splenomegaly.
  • Microscopic haematuria (glomerulonephritis or emboli).
  • Embolic events — stroke, limb ischaemia, septic pulmonary emboli (right-sided endocarditis).
  • Heart failure (valve destruction), new heart block (aortic root abscess).
• Next steps — three sets of blood cultures from different sites before antibiotics (if stable), urgent echo (TTE then TOE), urine dipstick, ECG (PR prolongation); see the Pericardial Disease and Endocarditis chapter.