Clinical method notes · Start with the patient, then use the findings to narrow the diagnosis.
The purpose of cardiovascular assessment is to answer four questions:
- Is the patient unstable?
- Which cardiovascular syndrome best explains the presentation?
- What is the likely cause or trigger?
- Which investigations will change management?
1. Recognise urgent presentations first
Urgent assessment is required for severe breathlessness or pulmonary oedema, ongoing chest pain suggestive of acute coronary syndrome, syncope with haemodynamic instability, a new focal neurological deficit, shock, suspected aortic dissection, or a tachyarrhythmia/bradyarrhythmia causing instability.
Use an ABCDE approach, call for senior/emergency help early, monitor vital signs, obtain IV access and an ECG when indicated. Give oxygen for hypoxaemia, not routinely to every patient. Do not delay stabilisation while taking a long history.
2. Focused cardiovascular history
Chest pain
Ask about onset, site, character, radiation, severity, duration, triggers, relieving factors and associated symptoms. Exertional pressure relieved by rest suggests angina; persistent pressure with sweating or nausea raises concern for acute coronary syndrome. Sudden tearing pain radiating to the back, syncope or pulse/BP differences raises concern for aortic dissection. Pleuritic pain may be pulmonary or pericardial rather than myocardial.
Breathlessness
Ask about exertional dyspnoea, orthopnoea (number of pillows), paroxysmal nocturnal dyspnoea, reduced exercise tolerance, cough and leg swelling. These can suggest heart failure, but respiratory disease, anaemia and pulmonary embolism are important alternatives.
Palpitations
Clarify sudden or gradual onset, duration, regularity, frequency, triggers, and whether there is chest pain, dyspnoea, dizziness or syncope. Ask about caffeine, alcohol, medicines and stimulant use.
Syncope or dizziness
Establish what the patient was doing, warning symptoms, duration, recovery, witnessed movements and post-event confusion. Exertional syncope, syncope while supine, known structural heart disease or a family history of sudden death are concerning features.
Swelling and vascular symptoms
Ask about bilateral ankle swelling, rapid weight gain, abdominal distension, calf pain/swelling, cold or painful limbs, ulcers and walking distance before leg pain begins.
Background and risk
Ask about hypertension, diabetes, dyslipidaemia, kidney disease, HIV where appropriate, rheumatic fever, previous cardiac disease, pregnancy-related hypertension, smoking, family history of premature cardiovascular disease, and all prescribed, over-the-counter and herbal medicines. Ask about adherence and recent changes.
3. Cardiovascular examination
Explain the examination, obtain consent, wash hands and position the patient appropriately. Expose the chest respectfully and examine the patient from the end of the bed before focusing on the precordium.
General inspection and observations
Look for distress, cyanosis, pallor, sweating, cachexia, oedema, scars, oxygen use and monitoring equipment. Record pulse rate and rhythm, blood pressure, respiratory rate, temperature and oxygen saturation. Assess capillary refill and peripheral perfusion.
Hands and pulse
Assess temperature, capillary refill, clubbing, peripheral cyanosis and signs of infective endocarditis when clinically relevant. Check pulse rate, rhythm, volume and character; compare radial pulses if indicated. Radio-femoral delay or unequal pulses may suggest vascular disease. Measure blood pressure with the correct cuff.
Face and neck
Look for pallor, central cyanosis and xanthelasma when relevant. Assess the jugular venous pressure with the patient at about 45 degrees. Inspect for raised JVP and hepatojugular reflux when appropriate. Examine the carotid pulse carefully; listen for bruits when indicated and never palpate both carotids simultaneously.
Precordium
Inspect for scars, deformity and visible pulsations. Palpate the apex beat for location and character; assess for heaves and thrills. Auscultate systematically at the aortic, pulmonary, tricuspid and mitral areas. Identify S1 and S2, then listen for added sounds, murmurs and pericardial rub. If a murmur is heard, describe timing, location, radiation, intensity and response to manoeuvres when appropriate.
Lungs, abdomen and legs
Listen for basal crackles or other signs of pulmonary congestion. Examine the abdomen for hepatomegaly, ascites and pulsatile masses where appropriate. Check for peripheral oedema and assess peripheral pulses. A cardiovascular examination is incomplete without looking for evidence of heart failure and peripheral vascular disease.
4. First-line investigations: ask what each test answers
- 12-lead ECG: rhythm, conduction, ischaemia/infarction, chamber strain and other electrical abnormalities. A normal ECG does not exclude acute coronary syndrome.
- Chest X-ray: cardiomegaly, pulmonary congestion, pleural effusions and alternative thoracic diagnoses.
- Echocardiography: ventricular function, chamber size, valves, pericardial fluid and structural disease.
- Troponin: myocardial injury; interpret serial values and the clinical picture, because elevation is not specific to coronary thrombosis.
- FBC: anaemia or infection that may cause or worsen cardiovascular symptoms.
- Urea, creatinine and electrolytes: renal function and electrolyte abnormalities, especially before or during diuretic and renin–angiotensin system treatment.
- Glucose/HbA1c and lipid profile: cardiovascular risk assessment.
- BNP/NT-proBNP: supports assessment of suspected heart failure; interpret alongside clinical findings and renal function.
- Additional tests: D-dimer, CT pulmonary angiography, blood cultures, thyroid tests or other tests only when the differential diagnosis and pre-test probability justify them.
5. Build a problem representation
Instead of listing every symptom, summarise the case in one sentence.
Example: “A 68-year-old with long-standing hypertension presents with progressive exertional dyspnoea, orthopnoea, bilateral ankle oedema, raised JVP and basal crackles, suggesting congestive heart failure.”
Then ask:
- Is the patient stable or unstable?
- Is this mainly heart failure, ischaemia, arrhythmia, valvular disease, pericardial disease or vascular disease?
- What could have precipitated it?
- What dangerous alternative must be excluded?
6. Clinical cases
Case 1 — Breathlessness and swelling
A 65-year-old with hypertension reports worsening breathlessness, needing three pillows to sleep, and bilateral ankle swelling. Examination reveals raised JVP and bilateral basal crackles.
Most likely syndrome: heart failure with congestion.
Next steps: assess ABCDE and oxygen saturation; obtain ECG, chest X-ray, renal function/electrolytes and natriuretic peptide if available; arrange echocardiography. Look for triggers such as myocardial ischaemia, arrhythmia, infection, uncontrolled BP, missed medication or renal deterioration. Treat acute congestion according to severity and local protocol.
Related reading: Heart failure.
Case 2 — Chest pain
A 54-year-old with diabetes develops central chest pressure while walking, radiating to the left arm, with sweating and nausea. The pain persists at rest.
Working diagnosis: acute coronary syndrome until excluded.
Immediate approach: urgent ECG, serial troponins, monitoring and senior/emergency assessment. Give antiplatelet and other ACS treatment according to contraindications and local protocol. Do not dismiss the case because the first ECG is non-diagnostic.
Related reading: Acute coronary syndrome.
Case 3 — Fever and a new murmur
A patient with fever has a new murmur and small painless lesions on the palms.
Consider: infective endocarditis.
Approach: obtain multiple blood-culture sets before antibiotics when this can be done without dangerous delay; arrange echocardiography and urgent specialist review. In an unstable patient, do not delay life-saving treatment for investigations.
Related reading: Infective endocarditis.
7. Exam checklist
When asked to assess a cardiovascular patient, state:
- Immediate stability assessment and vital signs.
- Focused history, including red flags and risk factors.
- General, peripheral, neck, precordial, lung, abdominal and leg examination.
- A concise problem representation and ranked differential diagnoses.
- Investigations with a reason for each.
- Initial stabilisation, cause-directed management, monitoring and reassessment.
Next topics
Proceed to hypertension and hypertensive emergencies, then heart failure, acute coronary syndrome, valvular disease and murmurs, infective endocarditis, ECG and arrhythmias, pericardial disease, cardiomyopathy, peripheral vascular disease and shock.
Educational revision notes, not a substitute for supervised clinical decisions. Use current Kenyan guidance and local protocols.