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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 step by step approach to examining the cardiovascular system, with an included video demonstration.  Check out the cardiovascular examination OSCE mark scheme here.

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? (remember to look underneath arms for thoracotomy scars and for small scars from minimally invasive surgery)

Inspect legs – scars from saphenous vein harvest for CAGB  / peripheral oedema / missing limbs or toes

Hands

Hands out with palms facing 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 and 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/clammycan be associated with acute coronary syndrome

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

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

Tar staining – smoker – risk factor for cardiovascular disease

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

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

  • Inspect nails

Pulses

Radial pulse – assess rate and 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
  • Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation
  • This is a water hammer 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 and character

 

Blood pressure:

  • Measure blood pressure and 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 and volume – e.g. slow rising character in aortic stenosis
  • It’s often advised to auscultate the carotid artery for a bruit before palpating, as theoretically palpation may dislodge a plaque which could lead to a stroke
  • However, if you perform carotid auscultation at this point, remember that the ‘bruit’ may actually be a radiating murmur!
  • Palpate radial pulse

Jugular venous pressure (JVP)

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 and 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
  • This is very uncomfortable to perform correctly – an examiner will often prevent you performing it but remember to mention it!
  • 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 the corners of the mouth – iron deficiency 

High arched palate – suggestive of Marfan syndrome – ↑ 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 (can be either side, so remember to check both)
  • Left mid-axillary line – subcutaneous implantable cardioverter defibrillator (ICD)

Chest wall deformities – pectus excavatum / pectus carinatum

Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy

  • Inspect chest for scars

Palpation

Apex beat:

  • Located at the 5th intercostal space / midclavicular line
  • Palpate the apex beat with your fingers (placed horizontally across the chest)
  • Lateral displacement suggests cardiomegaly

 

Heaves:

  • A parasternal heave is a precordial impulse that can be palpated
  • Parasternal heaves are present in patients with right ventricular hypertrophy
  • Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
  • If heaves are present you should feel the heel of your hand being lifted with each systole

 

Thrills:

  • A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
  • You should assess for a thrill across each of the heart valves in turn
  • To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed
  • 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  4th or 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 and listen to mitral area with bell during expiration – mitral murmurs (stenosis and regurgitation)
Lean forward and listen over aortic area during expiration – aortic murmurs are louder (stenosis and regurgitation)

  • Auscultate left sternal edge

A systematic routine will ensure you remember all the steps whilst giving you several chances to listen at each valve area.  Your routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps.  One such routine is shown in the video; an alternative is described below:

  • Start from mitral area
  • Listen ‘upwards’ through the valve areas using the diaphragm of the stethoscope (mitral -> tricuspid -> pulmonary -> aortic) using appropriate breathing manoeuvres
  • Repeat the process using the bell of the stethoscope
  • Continue upwards to the carotids (check for aortic stenosis radiation)
  • Sit forwards (check for aortic regurgitation radiation)
  • Roll onto to the left (check for mitral regurgitation)

To complete the examination

Auscultate lung bases:

  • Crackles may suggest pulmonary oedema (e.g. secondary to left ventricular failure)
  • Consider chronic lung diseases if the patient has no other signs of fluid overload (e.g. pulmonary fibrosis)

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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