Examination of the Heart

Author: Mr Vik Veer MBBS(Lond) MRCS(Eng) DoHNS(Eng) — December 2007. Updated 2025.

The following is one structured approach to examining the heart. There are many valid techniques and your examining style should evolve to suit your own approach. This guide assumes some knowledge of clinical medicine and is written with an OSCE or clinical exam setting in mind — you should be presenting your findings aloud as you examine, maintaining a running commentary that demonstrates your knowledge to the examiner. Talking constantly throughout the examination keeps the examiner engaged and allows you to demonstrate clinical reasoning even when findings are absent.

Introduction

Introduce yourself to the patient, confirm their name, and explain clearly what you would like to do. Ask for permission before beginning. In an exam context, establish eye contact with the examiner briefly before beginning your examination.

General Inspection

Step back from the patient and take a moment to survey the environment. Look for: oxygen, monitoring equipment (ECG leads, pulse oximetry), medications at the bedside (GTN spray, diuretics, anticoagulants), and any other equipment. Ensure the patient is adequately exposed — at least to the waist for a full cardiac examination.

"The patient is lying comfortably at rest at 45 degrees, and does not appear to be grossly cyanosed, anaemic, or in obvious pain or distress, nor does she appear breathless at rest."

Hands

Assess temperature using the dorsum (back) of your own hand — cool peripheries suggest low cardiac output. Look at the palms for pallor in the palmar creases (suggesting anaemia).

• Clubbing — loss of the normal angle between the nail and the nail bed, with bogginess of the nail fold and curvature of the nail. In cardiology, clubbing is associated with cyanotic congenital heart disease and infective endocarditis (IE).
• Koilonychia — soft, thin, brittle, spoon-shaped nails — indicates severe iron deficiency anaemia.
• Nicotine staining — yellow-brown staining of the fingers. Indicates the patient smokes cigarettes right down to the butt. It provides no quantitative information about the amount smoked.
• Quincke's sign — capillary pulsation visible in the nail bed when the nail is transilluminated or lightly compressed. Indicates aortic regurgitation (AR).
• Splinter haemorrhages — thin, dark, vertical lines under the nail running parallel to the long axis. More than 5 raises the suspicion of infective endocarditis (IE). Fewer splinters may simply reflect trauma.
• Osler's nodes — painful, tender nodules on the fingertips with a pale centre and red inflamed surround. Pathognomonic of IE (embolic or immune complex phenomena).
• Janeway lesions — painless, flat, dark erythematous macules or papules on the palms and soles. Seen in IE.
• Xanthomata — yellow lipid deposits over the extensor tendons (particularly the Achilles tendon and extensor tendons of the hands). Indicate familial hypercholesterolaemia.

Summarise your hand findings aloud as you go, for example:

"There are no peripheral signs of systemic disease in the hands."

Or, if positive:

"There are signs consistent with infective endocarditis in the hands — specifically, splinter haemorrhages in the right ring finger and a tender Osler's node on the right index fingertip."

Pulse

Palpate both radial pulses simultaneously — this detects absent or diminished pulsation on one side (suggesting an embolus, dissection, or arterial occlusion) and radio-radial delay (the right pulse arrives later than the left, suggesting coarctation of the aorta proximal to the right subclavian, or aortic dissection).

Concentrate on one wrist and assess:

Rate

Count the pulse for a full 60 seconds — in an exam, state you would do this and the examiner will normally allow you to move on rather than spend a minute at the wrist.

Rhythm

Regular, regularly irregular (e.g., second-degree heart block, multiple ectopics), or irregularly irregular (most commonly AF).

Waterhammer Sign (Corrigan's Pulse)

Lift the patient's arm above the level of the heart while palpating the radial pulse. A bounding, rapidly rising and collapsing pulse that becomes more prominent on elevation is the waterhammer (collapsing) pulse of aortic regurgitation. This is assessed at the wrist (radial) but is also visible in the neck as Corrigan's sign (visible neck pulsation without palpation).

Respiratory Rate

While apparently still counting the pulse, observe and estimate the respiratory rate — patients often breathe differently if they know they are being observed.

Blood Pressure

With the patient relaxed and the arm supported at heart level, inflate the cuff until the radial pulse is no longer palpable (palpatory systolic), then auscultate the brachial artery as the cuff is slowly deflated, listening for all five Korotkoff sounds. Record systolic (phase I — first sound) and diastolic (phase V — disappearance of sound).

• Pulsus paradoxus: a marked exaggeration (greater than 10 mmHg) of the normal inspiratory fall in systolic blood pressure. Occurs in cardiac tamponade and severe asthma. Measure the cuff pressure at which sounds are heard only in expiration, then in both phases — the difference is the pulsus paradoxus.
• Hill's sign: systolic blood pressure in the lower extremity exceeds the upper extremity by more than 20 mmHg — a sign of significant aortic regurgitation.

Carotid Pulse — Volume and Character

Palpate one carotid at a time (never both simultaneously — this risks causing syncope by occluding the cerebral circulation). The carotid pulse provides the best assessment of pulse character because it reflects central aortic pressure more faithfully than the radial pulse.

Pulse Volume

• Large amplitude (bounding): aortic regurgitation, high output states (thyrotoxicosis, anaemia, fever, pregnancy, AV fistula)
• Small amplitude (weak): aortic stenosis, low cardiac output, hypovolaemia

Pulse Character

• Slow-rising plateau (anacrotic) pulse: the pulse rises slowly to a delayed peak — characteristic of severe aortic stenosis. Also called pulsus parvus et tardus (small and slow).
• Collapsing (waterhammer) pulse: rapid, forceful upstroke with rapid collapse — characteristic of aortic regurgitation. Best felt at the wrist with the arm elevated.
• Corrigan's pulse: visibly collapsing neck pulsation in AR — seen without palpation in severe cases.
• De Musset's sign: rhythmic head-nodding with each heartbeat — a sign of severe AR causing large stroke volume.
• Bisferiens pulse: a double-peaked pulse felt in the same systole — seen in mixed aortic stenosis and regurgitation, and in hypertrophic obstructive cardiomyopathy (HOCM).
• Pulsus alternans: alternating strong and weak pulses with a regular rhythm — a sign of severely impaired left ventricular function.

Jugular Venous Pressure (JVP)

Inspect the JVP with the patient at 45 degrees, head resting comfortably and turned slightly to the left. Use natural light approaching from an angle, which helps visualise the gentle undulation of the JVP. The internal jugular vein is medial to the sternocleidomastoid muscle; the external jugular is lateral and more easily visible but less reliable as a pressure indicator.

The normal JVP is <3–4 cm above the sternal angle (of Louis). A raised JVP (more than 4 cm above the sternal angle) indicates elevated right atrial pressure.

Differentiating JVP from the Carotid Pulse

• JVP has its most prominent (visible) inward movement — it collapses inward, unlike the carotid which pushes outward
• JVP has two peaks per cardiac cycle and is non-palpable; the carotid has one outward pulsation and is palpable
• JVP rises with abdominal pressure (hepatojugular reflux) — gently press on the right upper quadrant (ask about pain first and obtain permission); this causes a transient rise in JVP
• JVP falls on inspiration (as intrathoracic pressure drops and blood flows into the thorax); Kussmaul's sign is the paradoxical rise in JVP on inspiration, seen in constrictive pericarditis and restrictive cardiomyopathy

JVP Waveforms

• a-wave: atrial contraction (occurs just before the carotid pulsation). Large a-wave = tricuspid stenosis, pulmonary stenosis, pulmonary hypertension, or complete heart block (cannon a-waves when atria contract against a closed tricuspid valve).
• x-descent: atrial relaxation
• c-wave: tricuspid valve bulging back into the right atrium at the beginning of systole (often not visible)
• v-wave: passive filling of the right atrium while the tricuspid is closed during ventricular systole. Large v-wave = tricuspid regurgitation.
• y-descent: tricuspid valve opens; blood flows from RA into RV. Deep y-descent = constrictive pericarditis.

Face

Inspect the face systematically:

• Malar flush (mitral facies) — red-blue discolouration of the cheeks. A classic sign of severe mitral stenosis due to reduced cardiac output and peripheral vasoconstriction.
• Xanthelasma — yellowish lipid deposits around the eyelids. Indicate hypercholesterolaemia (though may be present with normal cholesterol).
• Arcus senilis — a white or grey ring around the corneal margin. In patients under 50, it may indicate hyperlipidaemia; in older patients it is a normal finding.
• Conjunctival pallor — ask the patient to gently pull down their own lower eyelid to reveal the conjunctiva. Pallor suggests anaemia.

Buccal Mucous Membranes

• Blue discolouration of the lips and buccal mucosa — central cyanosis (indicates reduced arterial oxygen saturation)
• High arched palate — associated with Marfan syndrome (which causes aortic root dilatation and AR) and Down syndrome
• Muller's sign — pulsation of the uvula in time with the heartbeat — a sign of severe aortic regurgitation

Fundi

Offer to examine the fundi — in an exam the examiner will often decline in the interest of time. If examined, look for:

• Hypertensive retinopathy — know the Keith-Wagener-Barker grading (grade I–IV)
• Roth's spots — pale-centred retinal haemorrhages in IE
• Dancing retinal arteries (Becker's sign) in severe AR

Precordium

Inspection

"On inspection of the precordium there are no scars, deformities, or visible cardiac pulsation."

Scars to look for: median sternotomy (CABG, valve replacement); left lateral thoracotomy (closed mitral valvotomy, old coarctation repair); left infraclavicular scar (pacemaker or ICD implantation).

Palpation

Apex beat: The normal apex beat is at the 5th intercostal space in the mid-clavicular line. Be seen to calculate the mid-clavicular line and count down from the angle of Louis (2nd rib) to the 5th intercostal space before you feel for it. In an OSCE with a normal patient — work out where it should be first, then confirm it is there. If you find it displaced first and then calculate where it should be, the examiner will ask whether you think the patient is abnormal.

• Tapping apex beat: a palpable first heart sound — characteristic of mitral stenosis
• Forceful/heaving apex beat: indicates increased cardiac output or left ventricular hypertrophy (e.g., hypertension, aortic stenosis)
• Displaced apex beat: displaced laterally and inferiorly in left ventricular dilatation (e.g., dilated cardiomyopathy, severe AR)
• Left ventricular heave: rest the palm of the hand over the left parasternal area to feel a sustained, outward lift of the chest wall — indicates left ventricular hypertrophy
• Right ventricular heave (parasternal heave): felt at the left sternal border — indicates right ventricular hypertrophy (pulmonary hypertension, pulmonary stenosis)

Thrills: Palpate very lightly for thrills — palpable murmurs that feel like a cat purring:

• Apical thrill — systolic: mitral regurgitation; diastolic: mitral stenosis
• Left parasternal thrill — ventricular septal defect
• Basal thrill — systolic: aortic or pulmonary stenosis; diastolic: aortic or pulmonary regurgitation

Auscultation

High-frequency sounds are best heard with the diaphragm; low-frequency sounds (e.g., the diastolic murmur of mitral stenosis, the 3rd and 4th heart sounds) are best heard with the bell applied very lightly to the skin.

Auscultate each valve area with both the diaphragm and the bell:

• Apex (mitral area): 5th intercostal space, mid-clavicular line
• Lower left sternal edge (tricuspid area): 4th/5th intercostal space, left sternal border
• Upper left sternal edge (pulmonary area): 2nd intercostal space, left sternal border
• Upper right sternal edge (aortic area): 2nd intercostal space, right sternal border

While auscultating, place your left hand lightly on the carotid pulse to synchronise sounds with the cardiac cycle — this tells you whether a murmur occurs in systole (with the carotid pulse) or diastole (between pulses). It is easy to lose track of where you are in the cardiac cycle, especially with complex or slow rhythms.

Special Manoeuvres

• Left lateral decubitus position: Roll the patient to the left and auscultate the apex with the bell — this brings the left ventricle closer to the chest wall and accentuates the low-frequency diastolic murmur of mitral stenosis (and the third heart sound).
• Axilla: Pansystolic murmur of mitral regurgitation radiates to the left axilla.
• Carotid auscultation: Using the bell, auscultate each carotid artery for bruits. The ejection systolic murmur of aortic stenosis radiates to the carotid arteries.
• Sitting forward in expiration: Sit the patient forward and ask them to breathe out fully and hold it. Auscultate the lower left sternal edge with the diaphragm for the early blowing diastolic murmur of aortic regurgitation. Expiration brings the aortic root closer to the chest wall. Use the instruction: "Could you sit forward, breathe in deeply, breathe all the way out, and hold it there for me — thank you."
• Respiratory manoeuvres for murmur lateralisation: Murmurs louder on inspiration are right-sided (tricuspid and pulmonary valves — because inspiration increases venous return to the right heart). Murmurs louder on expiration are left-sided (aortic and mitral valves).
• Position rule for murmurs: As a rough guide in an exam if you cannot determine the murmur — murmurs loudest below the nipple level tend to be pansystolic (mitral regurgitation, TR, VSD); murmurs loudest above the nipple level tend to be ejection systolic (aortic or pulmonary stenosis). This is a simplification but is useful when pressed for an answer.

Heart Sounds

• S1 (first heart sound): closure of mitral and tricuspid valves at the start of systole — "lub"
• S2 (second heart sound): closure of aortic and pulmonary valves at the end of systole — "dub". Normally splits on inspiration (A2 before P2). Fixed split in ASD; paradoxical split in LBBB and severe aortic stenosis.
• S3 (third heart sound): early diastole — ventricular filling. In patients under 40 this may be normal (physiological). In older patients it indicates ventricular dilatation and heart failure. Best heard at the apex with the bell, in the left lateral position.
• S4 (fourth heart sound): late diastole — atrial contraction forcing blood into a stiff, non-compliant ventricle. Always pathological. Indicates left ventricular hypertrophy (hypertension, aortic stenosis, HOCM) or ischaemia.
• Opening snap: high-pitched sound in early diastole, immediately after S2 — the sound of the stiff mitral valve opening in mitral stenosis.
• Ejection click: high-pitched sound in early systole — heard in aortic or pulmonary stenosis (bicuspid aortic valve) or pulmonary hypertension.
• Mid-systolic click: characteristic of mitral valve prolapse — often followed by a late systolic murmur.
• Pericardial friction rub: a scratching, leathery sound in pericarditis, often described as a "walking on fresh snow" quality. Best heard at the left sternal edge with the patient sitting forward in expiration. May have 1, 2, or 3 components.

Murmurs — Classification

For any murmur, describe: timing (systolic / diastolic / continuous), character, grade (Levine scale I–VI), location, radiation, and any manoeuvres that change it.

Systolic murmurs:

• Ejection systolic: starts after S1, peaks in mid-systole, finishes before S2 — aortic stenosis (radiates to carotids), pulmonary stenosis, HOCM, innocent flow murmur
• Pansystolic: starts with S1, occupies all of systole, continues to (or through) S2 — mitral regurgitation (radiates to axilla), tricuspid regurgitation (increases on inspiration), VSD (harsh, left parasternal)
• Late systolic: after mid-systole — mitral valve prolapse

Diastolic murmurs:

• Early diastolic (immediately after S2, decrescendo, blowing): aortic regurgitation (heard at LSE sitting forward in expiration), pulmonary regurgitation
• Mid-diastolic (rumbling, after an opening snap): mitral stenosis (heard at apex, left lateral, with bell), tricuspid stenosis

Continuous murmur (throughout systole and diastole): patent ductus arteriosus (PDA) — "machinery murmur".

Lung Bases

Auscultate the lung bases bilaterally. Bilateral basal fine inspiratory crackles (crepitations) indicate pulmonary oedema secondary to left ventricular failure. At the same time, press firmly on the sacrum with your thumb to detect sacral oedema (indicating right ventricular failure / fluid overload in a patient who has been lying flat).

Abdomen

Ask about abdominal pain and seek permission before examining:

• Inspect for scars, visible pulsations, and swellings
• Palpate for an abdominal aortic aneurysm (AAA) — a pulsatile, expansile epigastric mass
• Palpate the liver — hepatomegaly with a pulsatile liver suggests tricuspid regurgitation; a smooth, tender liver suggests right heart failure (hepatic congestion)
• Palpate the spleen — splenomegaly in IE and in portal hypertension secondary to right heart failure
• Auscultate over the abdominal aorta and renal arteries for bruits (suggesting atherosclerotic disease or renal artery stenosis)

Legs and Peripheral Pulses

• Look for scars (e.g., long saphenous vein harvest scar from CABG — running along the medial aspect of the leg)
• Palpate the femoral pulse bilaterally — check for radio-femoral delay (the radial pulse arrives before the femoral pulse, suggesting coarctation of the aorta)
• Pistol shot femorals: a loud systolic sound heard with the stethoscope over the femoral artery — a sign of AR
• Duroziez's sign: compress the femoral artery partially with the stethoscope; a systolic-diastolic murmur is heard — sign of AR
• Palpate popliteal, posterior tibial, and dorsalis pedis pulses
• Look for varicose veins
• Assess for peripheral oedema — press firmly over the anterior tibia, dorsum of the foot, and sacrum (for bedbound patients). Document the level to which oedema extends (e.g., "pitting oedema to mid-shin bilaterally").

Conclusion

Summarise your findings in one or two sentences and then offer further investigations:

• Urinalysis for glucose (diabetes), protein (hypertensive nephropathy), and blood (infective endocarditis)
• Chest X-ray
• 12-lead ECG
• Echocardiogram (if you suspect a murmur or structural heart disease)
• Blood tests: FBC (anaemia), U&E (renal function, electrolytes), troponin (if ischaemia suspected), BNP/NT-proBNP (heart failure), blood cultures (IE)

Thank the patient and wash your hands.