Cardiovascular system examination OSCE Guide

CARDIOVASCULAR EXAMINATION – OSCE GUIDE

style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;">

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?

Inspect legs – harvest site scars / peripheral oedema / missing limbs or toes

General inspection

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 backIn 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 lostFinger 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/clammy– can 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

Assess for finger clubbing

Inspect palms

Assess capillary refill time

Pulses

Radial pulse – assess rate and rhythm

Radio-radial delay:

Palpate both radial pulses simultaneouslyThey should occur at the same time in a healthy adultA delay may suggest aortic coarctation 

Collapsing pulse – associated with aortic regurgitation

First ensure the patient has no shoulder painPalpate the radial pulse with your hand wrapped around the wristRaise the arm above the head brisklyFeel 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 sensationThis 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 stenosisWide pulse pressure is associated with aortic regurgitationOften 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 stenosisIt’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

Palpate radial pulse

Radial-radial delay

Palpate brachial pulse

Collapsing pulse

Measure BP

Palpate carotid 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 liverObserve the JVP for a riseIn 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 resultA positive hepatojugular reflux sign is suggestive of right sided heart failure / tricuspid regurgitation

Observe for a raised JVP

Assess for hepatojugular reflux

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

Inspect conjunctiva

Inspect mouth

Inspect for central cyanosis

Close inspection of the chest

Scars:

Thoracotomy – minimally invasive valve surgerySternotomy – 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

Inspect chest for deformities

Palpation

Heaves – left sternal edge – ventricular hypertrophy 

Thrills – palpable murmurs felt over aortic valve and apex beat

Apex beat:

5th intercostal space / midclavicular line kayak displacement suggests cardiomegaly Once located, count out the intercostal spaces to make it clear to the examiner you have located it

Palpate apex beat

Feel for thrills

Feel for heaves

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

Auscultate pulmonary valve

Auscultate tricuspid valve

Auscultate mitral valve

Repeat auscultation with bell

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

Auscultate axilla

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

Auscultate at heart apex using bell

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

Check for sacral oedema

Check for pedal oedema

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations:

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

posted by welfare jjambo >> www.welfarejambo.com