Cardiovascular examination frequently appears in OSCEs.  You’ll be expected to pick up the relevant clinical signs using your examination skills. This cardiovascular examination OSCE guide provides a clear concise, step by step approach, to examining the cardiovascular system, with an included video demonstration.

Introduction

Wash hands
Introduce yourself
Check patient details – name / DOB
Explain the examination
Gain consent
Position the patient at 45° with their chest exposed
Ask if the patient has any pain anywhere before you begin!

General Inspection

Bedside – treatments or adjuncts?GTN spray / O2 /medication /mobility aids
Comfortable at rest? - does the patient look in pain?
Shortness of breath at rest?
Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis
Inspect chest - scars or visible pulsations?
Inspect legs - harvest site scars / peripheral oedema / missing limbs or toes

Hands
Temperature - cool peripheries may suggest poor cardiac output / hypovolaemia

Sweaty/Clammy- can be associated with acute coronary syndromes

Capillary refill – normal is <2 seconds – if prolonged may suggest hypovolaemia
Colour – dusky bluish discolouration (cyanosis) suggests hypoxia

Nicotine staining – patient is a smoker – increased risk of cardiac disease
Finger clubbing – infective endocarditis / cyanotic congenital heart disease
Splinter haemorrhages – reddish/brown streaks on the nail bed - bacterial endocarditis

Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis

Osler’s nodes - tender red nodules on finger pulps / thenar eminence - infective endocarditis

Xanthomata - raised yellow lesions – often noted on tendons of wrist –  caused by hyperlipidaemia

  • Inspect palms
Pulses

Radial pulse – assess rate & rhythm
Brachial pulse – assess character
Radial-radial delay - radial pulses do not occur simultaneously – may suggest aortic coarctation 
Collapsing pulse – associated with aortic regurgitation

 

Blood pressure:

  • Hypertension / hypotension
  • Narrow pulse pressure is associated with Aortic Stenosis
  • Wide pulse pressure is associated with Aortic Regurgitation

 

Carotid pulse – assess character & volume – e.g. slow rising character in aortic stenosis

  • Palpate radial pulse
Jugular venous pressure

1. Ensure the patient is positioned at 45°

2. Ask patient to turn their head away from you

3. Observe the neck for the JVP – located inline with the sternocleidomastoid

4. Measure the JVP – number of cm from sternal angle to the upper border of pulsation

Raised JVP may indicate – right ventricular failure/ fluid overload/ tricuspid stenosis 

 

Hepatojugular reflux:

  • Apply pressure to the liver
  • Observe the JVP for a rise
  • In healthy individuals this should last no longer than 1-2 heartbeats (it should then fall)
  • If the rise in JVP is sustained & equal to or greater than 4cm this is a positive result
  • A positive hepatojugular reflux sign is suggestive of right sided heart failure / tricuspid regurgitation
  • Observe for a raised JVP
Face

Eyes

Conjunctival pallor – anaemia – ask patient to gently pull down lower eyelid
Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia
Xanthelasma – yellow raised lesions around the eyes –  hypercholesterolaemia

 

Mouth

Central cyanosis - bluish discolouration of lips / underneath tongue
Angular stomatitis – inflammation of corners of the mouth – iron deficiency 
High arched palate – suggestive of Marfans – ↑ risk of aortic aneurysm/dissection
Dental hygiene – important if considering sources for infective endocarditis

  • Inspect eyes
Close Inspection Of Chest

Scars- Lateral thoracotomy (mitral valve) / Midline sternotomy (CABG) / Clavicular (pacemaker)
Chest wall deformities – pectus excavatum / pectus carinatum
Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy

  • Inspect chest for scars
Palpation

Heaves- left sternal edge - seen in left & right ventricular hypertrophy
Thrills – palpable murmurs felt over aortic valve & apex beat
Apex beat – 5th intercostal space, midclavicular line – lateral displacement suggests cardiomegaly

  • Palpate apex beat
Auscultation
Auscultate the 4 valves

Palpate the carotid pulse to determine the 1st heart sound

Auscultate using the diaphragm of the stethoscope

Aortic valve 2nd intercostal space – right sternal edge
Pulmonary valve - 2nd intercostal space – left sternal edge
Tricuspid valve - 5th intercostal space – lower left sternal edge
Mitral valve - 5th intercostal space – midclavicular line (apex beat)

Repeat auscultation across the 4 valves with the bell of the stethoscope

  • Auscultate aortic valve

 

Radiation of the murmur

Carotid arteries – radiation of aortic stenosis murmur / carotid bruits

Axilla - radiation of heart murmur into the left axilla – mitral regurgitation

  • Auscultate carotid arteries
Accentuation maneuvers

These maneuvers cause particular murmurs to become louder

Roll onto left side & listen in mitral area with bell – mitral murmurs are louder
Lean forward & listen over aortic area during held expiration – aortic murmurs are louder

  • Auscultate left sternal edge
To complete the examination

Auscultate lung bases – crackles may suggest pulmonary oedema – left ventricular failure

Sacral oedema / Pedal oedema – may indicate right ventricular failure 

  • Auscultate lung bases

Thank patient
Wash hands
Summarise findings

Say you would….
Perform a full peripheral vascular examination 
Record a 12-lead ECG - arrhythmias / myocardial ischaemia 
Dipstick urine – proteinuria / haematuria – hypertension
Bedside capillary blood glucose – diabetes
Perform fundoscopy - malignant hypertension – papilloedema

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