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
Confirm 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

Provide clear instructions to the patient and minimise the amount of movements they need to make (don’t have them turning their hands back and forth multiple times)

Hands out with palms downwards

Splinter haemorrhages – reddish/brown streaks on the nail bed - bacterial endocarditis

Finger clubbing:

  • Ask the patient to place the nails of their index fingers back to back
  • In a healthy individual you should be able to observe a small diamond shaped window (Schamroth’s window)
  • When finger clubbing is present, this window is lost
  • Finger clubbing has a number of causes including infective endocarditis & cyanotic congenital heart disease

 

Hands out with palms facing upwards

Colour – dusky bluish discolouration (cyanosis) suggests hypoxia

Temperature - cool peripheries may suggest poor cardiac output / hypovolaemia

Sweaty/Clammy- can be associated with acute coronary syndromes

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

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

Nicotine staining – patient is a smoker – increased risk of cardiac disease

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

Capillary refill – normal is <2 seconds – if prolonged may suggest hypovolaemia

  • Inspect nails
Pulses

Radial pulse – assess rate & rhythm

Radio-radial delay:

  • Palpate both radial pulses simultaneously
  • They should occur at the same time in a healthy adult
  • A delay may suggest aortic coarctation 

 

Collapsing pulse – associated with aortic regurgitation

  • First ensure the patient has no shoulder pain
  • Palpate the radial pulse with your hand wrapped around the wrist
  • Raise the arm above the head briskly
  • You should feel a tapping impulse through the muscle bulk of the arm as the blood empties from the arm very quickly in diastole, resulting in the palpable sensation.
  • This is a Waterhammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g AR / PDA) or high output states (e.g anaemia / AV fistula / thyrotoxicosis)

 

Brachial pulse – assess volume & character

 

Blood pressure:

  • Measure blood pressure & note any abnormalities – hypertension / hypotension
  • Narrow pulse pressure is associated with Aortic Stenosis
  • Wide pulse pressure is associated with Aortic Regurgitation
  • Often you won’t be expected to actually carry this out (due to time restraints) but make sure to mention that you’d ideally like to measure blood pressure in both arms.

 

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 – Fluid overload / Right ventricular failure / Tricuspid regurgitation

 

Hepatojugular reflux:

  • Apply pressure to the liver
  • Observe the JVP for a rise
  • In healthy individuals this should last no longer than 1-2 cardiac cycles (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 the chest

Scars:

  • Thoracotomy – minimally invasive valve surgery
  • Sternotomy – CABG / valve surgery 
  • 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
  • Once located, count out the intercostal spaces to make it clear to the examiner you have located it
  • 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 (with breath held) – radiation of aortic stenosis murmur

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

Left sternal edge – Aortic regurgitation

  • Auscultate carotid arteries
Accentuation maneuvers

These maneuvers cause particular murmurs to become louder DURING expiration

Roll onto left side & listen to mitral area with bell during expiration – mitral murmurs (stenosis & regurgitation)
Lean forward & listen over aortic area during expiration – aortic murmurs are louder (stenosis & regurgitation)

  • 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

Suggest further assessments and investigations:

CONTENT REVIEWED BY

Dr Matthew Jackson – Interventional Cardiology SpR..

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