Introduce yourself, confirm the patient's name and date of birth. Explain the purpose of the examination, and obtain consent. Ask the examiner to act as a chaperone and then proceed to wash hands. Adjust the bed to a 45° angle.
General inspection
Begin the examination by inspecting the patient from the end of the bed. The patient should be exposed from the waist up. Offer a blanket to maintain their dignity and inform women that they may keep their undergarments on. Ask the patient
to expose their legs as well, as there may be some obvious oedema or venous ulceration.
Ask the patient if they are in any pain and are comfortable. Look out for the following signs which will give you a good indication of the state of the patient at rest.
Increased work of breathing: This can be due to several cardiac pathologies ranging from pericarditis to congestive heart failure.
Cyanosis: This suggests low tissue oxygen saturation and needs to be promptly addressed. Cardiac causes of cyanosis are usually congenital in nature (due to right-to-left cardiac shunting) or a result of abnormal haemoglobin.
Pallor: ßThis suggests anaemia or reduced perfusion, although it may just be the natural complexion of the patient.
Note any paraphernalia around the bedside, looking for clues such as oxygen and ECG leads. Patients with angina may have a glyceryl trinitrate (GTN) spray.
Do look for more subtle signs which may give clues to the patient's pathology. For example, a patient with cardiac failure may be using a large number of pillows, fluid restricted and fitted with a catheter to monitor urine output.
Hands
Inspection of the hands should be done in an intentional and noticeable way. Well perfused hands will be symmetrically warm and of a similar colour. Look at the nails carefully for clubbing (convex curvature of the nails), which could be a sign of congenital cyanotic
heart disease, infective endocarditis or atrial myxoma (CIA). Inspect the hand for other stigmata of endocarditis including:
Splinter haemorrhages: Tiny blood spots or splinters that occur under the nails following microhaemorrhages. Causes include trauma, infection (such as in infective endocarditis), psoriatic nail disease and vasculitis.
Janeway lesions: Painless macular lesions caused by septic emboli and are only present on the palms.
Osler's nodes: Painful, raised lesions usually present on the fingers
Examine the fingers, as long fingers(arachnodactyly) can be a sign of Marfan's syndrome, a risk factor for aortic dissection. Inspect the joints and palm for xanthomas (yellow cholesterol-rich deposits), which are indicative
of familial hypercholesterolaemia.
Next assess distal perfusion by recording the capillary refill time. Apply pressure to the distal phalanx of the patient's index finger for five seconds. The finger should turn pale but revert back to its normal colour within less than two seconds.
Poor perfusion is a sign of shock.
When assessing the palm for pallor, a good tip is to compare the patients palm to your own.
Temperature can be crudely assessed by placing the dorsal aspect of your hand on theirs and comparing.
The heart wall is made up of 3 layers. The epicardium (outermost), myocardium and endocardium (inner most). Inflammation of the endocardium secondary to infection is known as infective endocarditis. Organisms form vegetations on cardiac valves results in fever, heart murmurs and vascular phenomena (such as splinter haemorrhages).
Palpate the right radial pulse at the wrist to assess rate and rhythm. An irregular rhythm is commonly due to atrial fibrillation or the presence of ectopic beats. Rarer causes include bundle branch blocks or re-entrant tachycardias.
Palpate the left radial pulse to compare and check for radio-radial delay, which could be a sign of aortic coarctation or aortic dissection. Offer to check for radio-femoral delay, which will also present in these conditions.
When assessing rate, measure for 15s and multiply by 4.
An aortic coarctation is a congenital narrowing of the descending aorta. The severity of the disease is dependant on the degree and location of the narrowing.
Preductal coarctation (narrowing proximal to the ductus arteriosus) can be very serious as it can affect affects blood supply to the upper limbs and brain. Patients will severe narrowing will present early on in childhood and survival is dependant on a patent ductus arteriosus.
Ductal and postductal coarctation may only present in adulthood. Signs include hypertension in the upper limbs (with corresponding hypotension in the lower limbs), a scapular murmurweak femoral pulses and radio-femoral delay.
Aortic dissection is a condition in which there is a tear in the aortic intima creating a false lumen for blood to flow through. Presenting features include severe chest pain radiating to the back, syncope, arm blood pressure discrepency, a wide pulse pressure
Collapsing pulse
Ask the patient if they have any pain in their right shoulder. With your left hand, hold their right elbow and feel for the brachial pulse (medial to the distal tendon of the biceps brachii), and with your right hand, feel for the radial pulse.
Keep your hands in this position and lift the patient's arm up briskly (but gently) above the level of their heart and hold it. Palpate for a collapsing pulse, a gushing, "waterhammer" retraction of blood during the diastolic phase, a classic sign of aortic regurgitation.
Blood pressure
Check the patient's blood pressure. Ideally you would want to do this in both arms, as aortic dissection would present with a difference in blood pressure, and also when patient is both sitting and standing, as a difference would be found in postural (orthostatic) hypotension.
Aortic dissection: This can present with a blood pressure discrepancy of >20mmHg between each arm.
Postural hypotension: A decrease of >20mmHg in systolic, or >10mmHg in diastolic blood pressure when standing for more than 3 minutes when compared to rest. It is usually due to dysfunction of the autonomic nervous
system.
Face
Inspect the eyes for pallor (anaemia), corneal arcus (dyslipidaemia), xanthelasma (dyslipidaemia) and Kayser–Fleischer rings (Wilson's disease). The eyes may also appear sunken in a dehydrated patient. Check
the mouth for dental hygeine, as poor hygiene is a risk factor for infective endocarditis.
Inspect the tongue and palate. Macroglossia can be cause of amyloidosis whereas an atrophic, red tongue can occur in iron deficiency. A high arched palate can occur in Marfan's syndrome.
Central cyanosis can be observed on the lips or on the underside of the tongue. Finally check the cheeks for a malar flush, a sign of mitral stenosis.
Corneal arcus: A crescentic opacity of the eyes, which can be blue or white. This may occur in early childhood but it will eventually fade. It is also common in the elderly and is a sign of dyslipidaemia.
Kayser–Fleischer rings: These occur due to a hereditary condition known as Wilson's disease (hepatolenticular degeneration), in which copper deposition leads to dark circles encircling the iris.
Xanthelasma: Yellow deposits of fat under the skin near the eyelids. Associated with dyslipidaemia.
Assess the carotid pulse. The character of the waveform should be considered. A visible carotid pulse in the neck (Corrigan's sign,) is indicative of aortic regurgitation.
Ask the patient to turn their head to the left and observe their jugular venous pressure (JVP). In healthy patients, this should be no greater than 4 cm. This is measured as the vertical height from the angle of Louis (sternal angle) to the highest visible point where the JVP can be seen. If the JVP cannot be observed, pressure can be applied to the liver to elicit a hepatojugular reflux, however it may not be apparent in healthy individuals.
Character is best assessed by more experienced individuals. It could be described as normal, bounding (aortic regurgitation), thready (circulatory shock), or slow-rising (aortic stenosis).
When assessing the JVP it is important that the patient does not turn their head completely to the left nor tense their neck muscles. This could obscure visibility of the vein.
The JVP can be distinguished from the carotid pulse by its double pulsation.
A raised JVP is a sign of venous hypertension. Three common causes are:
Right-sided cardiac failure: This could be secondary to left-sided heart failure or due to the presence of pulmonary hypertension (cor pulmonale).
Tricuspid regurgitation: Usually secondary to right ventricular dilatation.
Constrictive pericarditis: Fibrosis of the pericardium. Can be caused by tuberculosis.
Praecordium
Inspection
Inspect the praecordium (chest area over the heart) for anterior scars, chest wall deformities (e.g. pectus carinatum/excavatum) or visible pulsations. Common scars include:
Midline sternotomy: Located in the midline of the thorax. Can be due to a previous coronary artery bypass graft, valve replacement or congenital correction.
Pacemaker scar: Located superiorly on the left thorax in the midclavicular line.
Axillary thoracotomy scar: Usually located at the 5th intercostal space in the anterior axillary line. Commonly due to a previous chest drain. (This is best assessed when inspecting the back).
Posterolateral thoracotomy scar: Usually located at the lateral and posterior intercostal space inferior to the tip of the scapula. Commonly due to a lobectomy or pneumonectomy. (This is best assessed when inspecting the back).
Common scars following cardiothoracic surgery.
Palpation
Palpate for the apex beat. This is usually found in the left 4th or 5th intercostal space in the midclavicular line. A displaced apex beat could be a result of ventricular hypertrophy. Palpate the areas of the four heart valves for thrills
(palpable murmurs, which feel like soft vibrations). The location of each valve is as follows:
Mitral area: The 5th intercostal space, midclavicular line.
Tricuspid area: The left 5th costo-sternal border.
Pulmonary area: The left upper sternal border at the 2nd intercostal space.
Aortic area: The right upper sternal border at the 2nd intercostal space.
Areas for palpation on the chest.
Finish palpation by checking for a left parasternal heave, as this is a sign of right ventricular hypertrophy.
It is good practise to localise the apex beat after having palpated it. This is done by keeping your right hand on the area of the apex beat and using your left hand alone to count the ribs from the angle of Louis.
Auscultation
Auscultate the four valves using the same landmarks as above with the diaphragm of the stethoscope (used to detect high-frequency murmurs). Be sure to palpate the carotid pulse whilst doing so in order to time any audible murmurs.
Listen for the 1st and 2nd heart sounds and for any additional abnormalities. If you hear a murmur, determine if it is systolic or diastolic by timing it with the carotid pulse.
Performing the following manoeuvres can help accentuate certain left-sided heart murmurs. Auscultation of these murmurs is preferably performed on end expiration (ask the patient to breath out and hold their breath).
A mid-diastolic murmur due to mitral stenosis can be accentuated by asking the patient to lie down on their left side. Auscultate over the mitral area using the bell of the stethoscope.
A pansystolic murmur due to mitral regurgitation may radiate to the axilla. Therefore, whilst the patient is still lying down, auscultate the axilla using the diaphragm once again.
An early diastolic murmur due to aortic regurgitation can be accentuated by asking the patient to sit up straight. Auscultate just left of the sternal edge, rather than in the aortic area.
An ejection systolic murmur due to aortic stenosis may radiate as high as the carotid arteries. Therefore, with the patient already sat up, finish by auscultating the carotid arteries.
It is absolutely vital that you only auscultate whilst palpating for the carotid pulse. This way you can easily determine if a murmur is systolic (in time with the pulse), or diastolic (immediately after the pulse).
Carotid bruits: After auscultating the neck for radiation of an ejection systolic murmur, it may be worth auscultating the carotids once again, but this time using the bell of the stethoscope. This will check for any carotid bruits, a
low-frequency, whooshing sound which presents with turbulent blood flow. Carotid bruits in younger patients are often "innocent," but if found in an older patient they usually suggest carotid artery stenosis.
The diaphragm of the stethoscope is best at detecting high frequency sounds. These include most murmurs and vesicular breath sounds. Pansystolic, early diastolic and ejection systolic murmurs are all most audible with the diaphragm.
The bell of the stethoscope is better at detecting low frequency sounds. These include a few murmurs, such as a mid-diastolic murmur in mitral stenosis, and vascular bruits. Vascular bruits will present with a systolic, low frequency,
"whooshing" sound on auscultation. They can be due to a very high rate of blood flow or otherwise turbulent blood flow as a consequence of partial obstruction of an artery.
Back
Complete inspection of the thorax by examining the back for posterior and lateral scars. Ask the patient if they have pain in their lower back. If not, gently palpate the sacrum for sacral oedema. Sacral oedema is more common in
patients who have been lying flat for a long period of time or are immobile. Finally, auscultate the lung bases for crepitations. Both sacral oedema and crepitations are present in left-sided heart failure.
It is good practise to move onto the back immediately after auscultating the carotids, as the patient will already be sitting up. You do not want the patient to be constantly changing position as this is both uncomfortable and unnecessary.
Ankles
Check the patient's ankles for pitting oedema, which is a sign of right-sided heart failure. Patients may also have peripheral vascular disease, particularly if they are known diabetics, so note any ulcers and offer to check for
peripheral pulses.
If the patient has a midline sternotomy scar, this could be a result of a coronary artery bypass graft. Therefore be sure to check the entire knee, leg and ankle for scars due to saphenous vein harvesting.
Completion
Complete the examination by offering to obtain a full history, perform basic observations including temperature and oxygen saturation, carry out a urine dipstick (to look for microscopic haematuria, which may present in infective endocarditis), and (if appropriate), perform a 12-lead electrocardiogram and carry out fundoscopy (a "silver-wiring" effect and microaneurysms may be seen in hypertension and Roth's spots may be seen in infective endocarditis).
Additional notes
A pulsatile liver can be a sign of tricuspid insufficiency, and splenomegaly can occur in endocarditis. Also, if you suspect that the patient may have an abdominal aortic aneurysm, and an abdominal examination may be indicated.
Key
Headings - items highlighted in green are important headings to cover.
Definitions
Stigmata - a clinical sign relating to a particular condition. E.g. clubbing and infective endocarditis.
Paraphenalia - equipment the patient may have by the bedside.
Presentation
Thank you for allowing me to conduct a cardiovascular examination on [patient's name], a [age] year old [male/female]. On general inspection, there were no paraphenalia to suggest disease, and the patient appeared comfortable and well at rest. The patient's hands were warm and well perfused. The pulse was regular at [x beats per minute], with no radio-radial delay. I would like to formally assess blood pressure and radio-femoral delay. On examination of the head, there were no stigmata of anaemia, and dentition appeared normal. In the neck, the jugular venous pressure was normal (below 4cm).
On closer inspection of the chest, there were no scars to suggest previous surgery. The apex beat was palpable in the fifth intercostal space, in the mid-clavicular line. There were no heaves or thrills. Heart sounds SI + SII were present, with no added sounds. There was no peripheral oedema. To conclude, this was a normal cardiovascular examination .
Interactive markscheme
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I need to examine your heart and chest today, would that be okay? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone."
Wash hands.
Position the bed at a 45° angle and ensure adequate exposure.
Ask about pain and discomfort.
Inspect the patient (work of breathing, pallor, cyanosis) and their surroundings (ECG leads, oxygen).
Inspect the hands for: warmth, clubbing, peripheral cyanosis, stigmata of endocarditis (splinter haemorrhages, Janeway lesions, Osler’s nodes).
Check capillary refill.
Test for radial-radial delay AND offers to test for radio-femoral delay.
Take the pulse for 15 seconds (assess for rate and rhythm).
Enquire about shoulder pain and then assess for a collapsing pulse.
Ask to take the blood pressure in both arms, sitting and standing.
Inspect the face (malar flush), eyes (pallor, corneal arcus, xanthelasma) and mouth (central cyanosis, poor dentition).
Assess the jugular venous pressure. If it cannot be seen, offer to test hepatojugular reflux.
Palpate the carotid pulse on both sides to assess character.
Inspect the precordium again in closer detail for scars and deformity.
Palpate for the apex beat and assess its position.
Palpate for heaves and thrills.
Auscultate all areas of the heart appropriately.
Time auscultation with the carotid pulse.
Perform mitral stenosis manoeuvre (left side on expiration) and listen in the axilla for radiation (mitral regurgitation).
Perform aortic regurgitation manoeuvre (sit up and listen to pulmonary area on expiration).
Auscultate the carotids for any bruits/radiation (aortic stenosis).
Auscultate the lung bases.
Palpate for sacral oedema.
Palpate the legs for peripheral oedema/harvesting scars.
Thank and cover up the patient.
"To conclude, I would like to take a full history, assess the peripheral pulses, look at any old ECGs, and carry out a urine dipstick/fundoscopy to look for signs of infective endocarditis.”
