FFinalistSouthampton · 2027
Examinations

CPSA · Clinical examination · Cardiovascular

Cardiovascular examination

A focused precordial exam — inspect, palpate, auscultate the four valve areas, then look for heart failure. The commonest OSCE examination; a slick routine scores across every domain.

Practise it out loud

Position: Patient reclined at 45°, chest exposed, head supported.

The routine

General inspection
  1. 1End of the bed: comfortable at rest? breathless, cyanosed, cachectic?
  2. 2Around the bed: GTN spray, oxygen, fluid restriction sign, medications, mobility aids
Hands
  1. 1Inspect: clubbing, splinter haemorrhages, Janeway lesions, Osler’s nodes (endocarditis), tar staining, peripheral cyanosis, tendon xanthomata
  2. 2Temperature; capillary refill (<2 s)
  3. 3Radial pulse — rate & rhythm; radio-radial delay (coarctation/subclavian stenosis)
  4. 4Offer to check for a collapsing pulse (aortic regurgitation)
  5. 5Blood pressure (state you would measure it; wide pulse pressure = AR, narrow = AS)
Face & neck
  1. 1Eyes: conjunctival pallor (anaemia), corneal arcus, xanthelasma
  2. 2Mouth: central cyanosis, high-arched palate (Marfan), dental hygiene (endocarditis risk)
  3. 3Assess the JVP (raised in right heart failure/fluid overload); hepatojugular reflux
  4. 4Palpate the carotid pulse — character (slow-rising = AS, collapsing = AR)
Praecordium — palpate
  1. 1Apex beat — normally 5th intercostal space, mid-clavicular line (displaced in cardiomegaly; heaving = pressure overload, thrusting = volume)
  2. 2Heaves (left parasternal = RV hypertrophy) and thrills (palpable murmur)
Praecordium — auscultate
  1. 1Four areas — Aortic (2nd R ICS), Pulmonary (2nd L ICS), Tricuspid (4th L ICS), Mitral (5th ICS MCL) — “APTM”
  2. 2Time each murmur against the carotid pulse (systolic vs diastolic)
  3. 3Accentuate: mitral — left lateral, bell, expiration; aortic — sitting forward, expiration
  4. 4Auscultate the carotids for radiation/bruits, and lung bases for crepitations

Signs & what they mean

Ejection-systolic murmur radiating to carotids + slow-rising pulseAortic stenosis
Early-diastolic murmur (sitting forward) + collapsing pulse + wide pulse pressureAortic regurgitation
Pan-systolic murmur radiating to axillaMitral regurgitation
Mid-diastolic rumble, loud S1, tapping apex (left lateral)Mitral stenosis
Splinter haemorrhages, Janeway lesions, Osler’s nodes, new murmurInfective endocarditis
Raised JVP, peripheral oedema, bibasal crepitationsCongestive cardiac failure

To complete, I would…

  • Examine the peripheral vascular system and for peripheral/sacral oedema
  • Check the observations, an ECG, and a urine dip
  • Perform fundoscopy if endocarditis/hypertension suspected

OSCE tips

  • Time murmurs against the carotid, not the radial (radial lags).
  • Know the two accentuation manoeuvres (left lateral for mitral, sitting forward for aortic).
  • Always comment on the JVP — commonly forgotten.
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