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Introduces self
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Confirms name & age of patient
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Explains & gains consent
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Washes hands
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Exposes patient from waist up and positions at 45 degrees
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Asks if patient is in pain
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General inspection around bed & patient (breathing, scars,
sounds)
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Feels hands for temperature changes, cyanosis, capillary refill time
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Checks hands for nail clubbing, splinter haemorrhages, Janeway
lesions, Osler nodes and tar stains
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Feels radial pulse and comments on rate & rhythm
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Asks for blood pressure
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Feels carotid pulse, comments on volume & character
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Checks for water hammer pulse
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Inspects eyes for conjunctival pallor, corneal arcus, xanthelasma and
face for malar flush
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Inspects mouth for central cyanosis, dental hygiene, high arched
palate
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Assesses and comments on JVP
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Palpates apex beat
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Palpates for heaves & thrills
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Auscultates over mitral area on expiration leaning on left. Listens
for radiation in axillary area
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Auscultates over tricuspid area with patient leaning forward on both
inspiration and expiration
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Auscultates over pulmonary area on inspiration
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Auscultates over aortic area on expiration and carotids for radiation
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If murmur present comments on intensity, site, character, pitch,
radiation
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Listens over lung bases
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Feels for oedema
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Thanks patient and offers help to redress
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Washes hands
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Requests to palpate pulses, ECG, dip urine, fundoscopy
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Summarises appropriately with only key findings
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Offers appropriate differential diagnoses
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Patient global score
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Potential differentials
- Murmurs
- Aortic stenosis is with slow rising & low volume pulse, narrowed pulse pressure, heaving and sustained apex beat, ejection systolic murmur in aortic area radiating to carotids.
Differentials: - Aortic sclerosis (doesn't radiate to carotids)
- Mitral regurgitation (pansystolic radiating to axilla)
- HOCM (gets quieter on squatting whereas AS gets louder)
- Aortic regurgitation (rarer) with collapsing pulse, widened pulse pressure, thrusting apex beat, early diastolic murmur in left lower sternal edge
- Prosthetic valves
- Aortic valve replacement: midline sternotomy, second heart sound lost with opening click (A2 specifically), can get aortic regurgitation murmur
- Mitral valve replacement: midline sternotomy OR lateral thoracotomy, S1 lost with opening click, can get mitral regurgitation murmur
- Look for bruising of anticoagulation
- Pacemaker/defibrillator
- Scars: midline sternotomy with venous grafting scar on leg suggestive of CABG
- Atrial Fibrillation: look for bruises suggestive of anticoagulation