1. Greet examiner and thank them
2. Position briefcase on safe bench and open it
3. Take out stethoscope and place around neck
   1. note college does not allow electronically augmented stetoscopes unless medically cleared
4. Wash hands
5. Introduce yourself and shake the patient's hand (gain evidence about weakness)
   1. Standardised way: Hello Mr/Mrs ... My name is Dr ... Thank you for letting me examine you today
6. Position patient
   1. Make sure bed is at 45 degrees
   2. Expose chest wall
      1. If female re-cover with towel or apron until palpation and auscultation is required
7. Make a general examination of appearance by...
   1. standing back and looking for equipment (eg oxygen, IV lines, infusions such as flucloxacillin in a patient with MSSA endocarditis)
   2. standing back and observing patient (de mussett's sign of head nodding in aortic stenosis). Other signs include marfinoid habitus, arachnodactyly 
8. Examine both hands
   1. start at nails --> splinters for signs of infective endocarditis
   2. examine for clubbing --> shammroth's sign, palpate nail bed, look sidewards at nails
9. Examine both palms
   1. Osler's nodes
   2. Janeway lesions
10. Palpate the right radial artery
    1. Note volume (low, bounding)
    2. Character (slow rising, bisferens, collapsing)
    3. Rhythm (irregular)
    4. Rate --> feel for 15s (and multiply pulse x 4)
11. Palpate for radio-radial delay
12. Ask to palpate the femoral pulse
    1. Is it ok if I can feel the pulse in your groin?
13. Palpate for radio-femoral delay
14. Palpate for bracho-radial delay
15. Ask the patient if their shoulder is sore
16. Raise the arm whilst palpating the radial artery
    1. Examine for the water-hammer sign of aortic regurgitation
17. Measure the patient's blood pressure
18. Repeat the blood pressure out loud 
19. Ask the examiner for temperature and saturations and repeat it back (so you remember them)
20. Examine the patient's eyes
    1. Can you please look upwards
    2. Examine their conjunctiva for signs of anaemia (infective endocarditis, Heye's syndrome, intravascular haemolysis associated with a prosthetic valve)
    3. Note xantholesma arcus senilis, evience of lens dislocation, blue sclera
21. Examine the patients mouth with a pen torch
    1. Can you please open your mouth
    2. Look for central cyanosis, high arched palate, poor dentition, ulcers
22. Look for JVP by turning the patients head slightly away from you
    1. Use a pen torch if lighting allows tangentially
    2. Look for double flicker
    3. Look closely for the loss of 'a' waves in atrial fibrillation and the systolic 'v' waves
    4. Measure the venous pressure vertically from the sternal angle
    5. Attempt to occlude the venous pressure and observe for loss of double flicker and venous filling
    6. Are you tender anywhere in the abdomen Mr/ Mrs X?
    7. Elicit the hepato-abdominal reflex by pressing gently on the liver, feel for signs of pulsatile liver at the same time
23. Look and palpate the carotid arteries
    1. Elicit the dancing carotid sign (Corrigan's sign) of aortic regurgitation by tracing the visible carotid impulse and proving that it does not occlude
    2. Palpate the carotid pulse with the right hand (first right then left carotid artery of patient)
    3. Auscultate with bell (apply low pressure on stethoscope without bell)
24. Expose the precordium in females (the males precordium should have already been exposed)
25. Inspect chest wall thoroughly
    1. Look for obvious deformities - eg 
    2. Feel for devices (pacemaker box, AICD, CRT-D)
    3. Tract the midline sternotomy scar, or the hemisternotomy scar with the right index finger
    4. Tract the mitral valvotomy scar in the left lateral chest with the right index finger
    5. Trace the radial artery harvest scar with the right index finger
    6. Trace the saphenous vein harvest scar with the right index finger
26. Measure out and locate the apex beat
    1. Measure rib spaces down
    2. Measure displacement laterally (MR, HOCM, AR, dilated cardiomyopathy)
    3. Palpate for tapping apex beat of MS
    4. Palpate for heaving apex beat of AS
    5. Palpate for thrusting apex beat of MR and AR
27. Palpate the left sternal edge 
    1. Use right hand vertically
    2. Palpate for right ventricular heave
    3. Use right hand horizontally across the sternum, with fingers in the pulmonary area
    4. Palpate for P2
28. Palpate the aortic area
    1. Right hand right sternal edge, second interspace
    2. Palpate for aortic thrill
29. Auscultate at the Apex 
    1. Use the diaphragm and bell of the stethoscope and note the following information
       1. S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
       2. Take a big breath in and hold it for me please? 
       3. Can you take a breath out for me and hold it please?
30. Role the patient to left lateral position
    1. Can you please role slightly to your left side
    2. Palpate the apex beat again
    3. Use the diaphragm and bell and note the following information
       1. S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
       2. Can you hold you breath in for me please? 
       3. Can you take a breath out for me and hold it please?
31. Role the patient onto the back
    1. Can you please roll on to your back again? Thank you. 
32. Auscultate over the axilla for radiation of MR (or AS)
33. Auscultate over tricuspid area with the diaphragm and note the following information
    1. S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
    2. Can you hold you breath in for me please? 
    3. Can you take a breath out for me and hold it please? 
       1. TR gets louder on inspiration
34. Auscultate over the left sternal edge (VSD, AR)
35. Auscultate over the pulmonary area (PR, PS)
36. Auscultate over the aortic area (AS)
37. Sit the patient forward
    1. Please sit forward for me
    2. Feel for an aortic thrill
    3. Auscultate over the aortic area with the diaphragm and note the following information
       1. S1 (presence, amplitude), S2 (presence, amplitude, split), added (opening snap, systolic click, S3, S4), murmur
       2. Can you hold you breath in for me please? 
       3. Can you take a breath out for me and hold it please? 
    4. Auscultate over the LSE and RSE for AR
38. If you have determined the presence of a systolic murmur perform the valsava as follows
    1. Can you please pinch your nose
    2. Take a big breath in and...
    3. Try and unblock your nose
39. Sit the patient forwards again
40. Percuss for an effusion from the top of the lungs posteriorly down to the bottom
41. Auscultate for an effusion quickly
42. Palpate for sacral oedema
43. Palpate for pitting oedema
44. Lie the patient flat in bed and palpate for hepatomegaly
    1. Start at the right iliac fossa and move upwards whilst asking the patient to take big breaths in and out
45. Repeat the following statement to complete the examination
    1. I would like to complete my examination by performing fundoscopy, perform a urinalysis and a bedside ECG