Inspect from side of bed for any signs of difficulty or breathing etc

Inspect hands of the patient, looking for signs that might indicate signs of cardiovascular pathology, specifically nail beds etc.

Feel the radial pulse - just proximal to the wrist joint on the lateral side.

Assess the

• Rate - how many pulsations in a minute
• Rhythm - regular/regularly irregular/irregularly irregular
• Volume - how strong the pulse is
• Character - attributes of the pulse. E.g. rise and collapses quickly, or slow to rise to peak.

Lift patient's arm up, but ask them if they have any pain in their shoulder before you do so.

Good idea to palpate the brachial artery next - because radial artery can be weak. It is just medial to the biceps tendon.

Then, check eyes, looking for signs of anaemia etc.

Check mouth, lift roof of tongue up - looking for a high-arched palate. Associated with Marfan Syndrome. Also looking for state of dentition, and assessing for cyanosis.

Look for jugular venous pressure - looking for venous pulsation in the internal jugular vein, between the two heads of the sternocleidomastoid. It is a double pulsation, which you normally won't see in healthy people. Raised in certain heart conditions. Seen in complete heart block.

To test if it is low or not we do the hepatojugular reflux, palpating at the bottom of the liver to increase venous return, and sometimes we see the JVP rising as a result.

If it is raised above 4cm from the manubriosternal joint, this is abnormal.

Press on stomach, palpate the just under the liver for a few seconds to see the JVP rise. If you tense the muscles in the neck it can be harder to see the JVP. It should not be a palpable pulse, helping you distinguish it from the carotid pulse.

Next, you can examine the carotid pulse. Often easiest to locate the trachea then move slightly laterally to feel the pulse.

Maintaining patient dignity is important. It is important to keep them covered as much as you can. But expose their chest to inspect to precordium.

Stand back, see how the chest is moving. Look for any obvious chest wall deformities, or any scars. Most common is one down the middle of the chest. Look for any scars in the lateral edge of the chest and again on the left hand side. In women the scar can be under the breast, so it is important to move the breast. Look in the left hand side of the chest in the mid-axillary line. Subcutaenous defibrillators can often be observed.

Examine chest, after asking if patient is sore.

Female precordium assessment

Palpate the apex beat, found in the 5th intercostal space. If you can't feel it, move around to see if it is displaced.

Then, feel over the different areas if there are any palpable murmurs or heaves. Place the palm of the hand just towards the left of the sternum. If there is right ventricular hypertrophy etc, you'll feel your hand being lifted off the chest. If you keep your elbow at a slight angle you'll be able to feel it more easily as well.

Now listen to the chest, using bell of stethoscope. Listen to the mitral area, tricuspid area, pulmonary area and the aortic area in sequence. Then listen to those areas again with the diaphgram of the stethoscope.

It is good practice to palpate the carotid pulse in turn with auscultation, so you can time murmurs with the pulse. This allows you identify if the murmur is systolic or diastolic, and which heart sound you are listening to.

Often easiest to start with the bell to listen to all four areas. When you place the bell, place it very softly.

If you hear a murmur suggesting that the patient has mitral stenosis, you can do some things to ensure you hear it better!

• Get patient to roll over to left side and hear with the bell of the stethoscope.