Medically Fit For Exams
Medically Fit For Exams

Cardiovascular examination abnormalities

Heart failure

  • May be on oxygen, appear cyanosed
  • Cool peripheries
  • Slow capillary refill
  • Tar staining (smoking is a risk factor)
  • May have tachycardia or bradycardia depending on medication and stage of disease
  • Central cyanosis (under tongue)
  • Raised JVP
  • Cardiomegaly (displaced apex beat)
  • Heave (left ventricular hypertrophy)
  • Fine crackles at the lung bases (pulmonary oedema)
  • Sacral and/or peripheral oedema (reduced venous return)
  • Signs of mitral regurgitation (LV dilation)



  • Raised JVP (venous/pulmonary hypertension)
  • Left ventricular hypertrophy
    • Displacement of the apex beat
    • 4th heart sound (‘Tenessee’)
  • Carotid bruit
  • Distended veins in the neck
  • Fine crackles in the lung bases (pulmonary hypertension)


Mitral regurgitation

  • Pan systolic murmur over apex
  • Radiates to axilla
  • May hear 3rd heart sound (‘Kentucky’)
  • May have left parasternal heave
  • May have ‘thrusting apex’


Aortic stenosis

  • Early systolic murmur over right 2nd intercostal space
  • Radiates to neck
  • May hear 4th heart sound (‘Tennessee’)
  • Slow rising pulse
  • Narrow pulse pressure
  • Systolic thrill
  • Apex beat displacement unlikely


Mitral stenosis

  • Mid diastolic murmur over apex
  • No/little radiation
  • Rumbling/low pitched
  • Starts with opening ‘snap’
  • Left parasternal heave
  • Malar flush


Aortic regurgitation

  • Early diastolic murmur over the left 4th intercostal space
  • Radiates to neck
  • Best heard with breath held, with patient sat forwards
  • Wide pulse pressure
  • Collapsing or bounding pulse
  • Apex beat displacement
  • Capillary pulsation in nail bed (Quincke’s sign)
  • Head nodding with heart beat (De Musset’s sign)



Mitral regurgitation

Mitral stenosis

Aortic stenosis

Aortic regurgitation


Pan systolic

Mid diastolic

Early systolic

Early diastolic (often also ejection systolic murmur from volume overload)



Low pitched


High pitched




R 2nd intercostal space (aortic area)

R 2nd intercostal space

Patient position?


?Roll on to side

Lean forwards,

Lean forwards, breath held out






Added sound?

3rd heart sound (Kentucky)

Opening ‘snap’

Ejection click, 4th heart sound (Tennessee)



L parasternal heave, thrusting apex

L parasternal heave

Systolic thrill



Ischemic heart disease

  • Tar staining
  • Sweaty/clammy hands (if currently having ischaemic episode)
  • Increased capillary refill time
  • Xanthalasma
  • Corneal arcus
  • Peripheral cyanosis


Infective endocarditis

  • Fever
  • Tachycardia
  • Splinter haemorrhages (vertical red/brown lesions under the fingernails)
  • Janeway lesions on palmar surface
  • Osler’s nodes on finger pulps
  • Clubbing
  • Irregular pulse
  • Distended neck veins
  • Mitral regurgitation
  • Aortic regurgitation



  • Koilonychia
  • Tachycardia
  • Irregular pulse
  • Facial and conjunctival pallor
  • Glossitis
  • Angular stomatitis

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