Examine the cardiovascular system.

• Look for clubbing of hands (cyanotic heart disease), splinter haemorrhages (endocarditis)
• Inspect the chest for surgical scars and movement
• Pulse (rate, rhythm, character)
• Blood Pressure
• Palpate the apex beat (normally 5th intercostal space, mid-clavicular line)
  • Is it heaving (mitral or aortic regurg or VSD)?
  • Thrusting (aortic stenosis, hypertension, HOCM)?
  • Diffuse (LV failure)?
  • Is there dextrocardia?
• Auscultate the heart:
  • Listen with the bell and the diaphragm at the apex (mitral area)
  • Identify first and second heart sounds
  • Listen for added sounds
  • Repeat at the lower left sternal edge and in aortic and pulmonary areas (right and left of manubrium)