Cardiovascular System OSCE Examination

Clean your hands (wash them or use alcohol hand rub) before you touch the patient. Introduce yourself to the patient and state your grade, for example third-year medical student, junior doctor or consultant.

Confirm the patient’s details using three points of identification, usually full name, date of birth and NHS or hospital number.

Obtain consent for the examination, and explain what it will involve.

Position the patient appropriately at 45° on the bed.

Exposing the chest may involve exposing the breasts, so offer the patient a chaperone (an impartial observer, usually a health professional) and explain what their role would be. The GMC advises this for intimate examinations, which it says are likely to include examinations of the breasts. Do not assume that the patient does not want one.

Then expose the patient’s chest appropriately (this can be done after examining the patient’s hands, arms, face and neck).

When assessing the colour of the patient, it is important to look for any signs of cyanosis or anaemia. A cyanotic patient would have a bluish tinge to their skin due to a lack of oxygen. A patient with severe anaemia could appear pale. This is because there is less haemoglobin, which usually gives blood (and therefore the skin) its pink colour. It is also important to assess how comfortable and aware (conscious) a patient is. If the patient has an acutely lowered conscious level or is in extreme pain, call for help. 

When examining the dorsum (back) of the hands, the patient may present with tendinous xanthoma. This is caused by an accumulation of lipids in large foam cells (macrophages filled with fat) within the tendons, resulting in raised, yellowish nodules. This can be caused by familial hyperlipidaemia.

Image - Tendinous xanthoma affecting multiple digits of both hands

Creative commons source by Kumar et al. (2008) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

When examining the nails, look for signs of splinter haemorrhages and koilonychia. Splinter haemorrhages are thin red or reddish-brown lines of bleeding under the nail, running along its length. They often follow an injury to the nail, but can also be a sign of infective endocarditis (infection of the inner lining of the heart, usually the valves). In endocarditis, a vegetation (a clump of bacteria and clot) on a heart valve can break up into tiny emboli (fragments carried in the blood). These may lodge in the small vessels under the nail.

Koilonychia, also known as spoon nails, is when the nails appear to curve in a concave way. This is most commonly associated with iron deficiency anaemia. It is unclear why this sign occurs.

Image - Splinter haemorrhages under the nails. They can be a sign of infective endocarditis, when tiny emboli lodge in the small vessels under the nails

Public Domain Source Splarka [Public domain]

Two skin signs of infective endocarditis are often confused, and tenderness is what separates them. Osler’s nodes are tender, raised nodules, usually on the pulps (pads) of the fingers and toes. Janeway lesions are non-tender, flat, red spots (erythematous macules) on the palms and soles. How both signs form is still debated. Under the microscope, both can show septic emboli (small infected fragments carried in the blood) with microabscesses (tiny collections of pus) in the skin. Remember ‘Osler = Ouch’. Tenderness tells the two apart, and looking only at the palms will miss Osler’s nodes. Neither sign is common: they are found in only about 5 to 15% of people with infective endocarditis.

Image - Janeway lesions on the sole of the foot. These are a sign of infective endocarditis, in which septic emboli (small infected fragments) can lodge in the skin

Creative commons source by DeNanneke [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

The fingers may show signs of peripheral cyanosis, which would be seen as a bluish tinge to the fingertips. Peripheral cyanosis is due to the inability of the body to perfuse the extremities. This can be caused by low blood pressure, hypothermia (low body temperature) or heart failure.

Image - Peripheral cyanosis in the hands. This is due to the fingertips not being adequately perfused

Creative commons source by James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Finger clubbing (swelling and rounding of the fingertips) is recognised by several signs. A positive Schamroth’s test (demonstrated in the video) is one of them: the diamond-shaped gap that normally appears between the nails of two opposed fingers is lost. Clubbing is a sign of a variety of different conditions, including heart, lung, liver and bowel disease. In the cardiovascular system, clubbing could be a sign of chronic hypoxia (long-term low oxygen levels), infective endocarditis and some congenital heart defects.

Image - The difference in the Schamroth’s window test. The bottom image shows a patient with clubbing as there is no gap between the fingernails

SimpleMed original by Dr. Bethany Turner

Capillary refill time is a test used to assess the perfusion of the fingers. This test is carried out by pressing on one of the patient’s fingers for five seconds. Once the finger is released, it should turn from a pale white, back to its normal colour in less than two seconds. If it takes longer than two seconds to reperfuse, then this may be a sign of shock, impaired peripheral perfusion or dehydration.

When assessing radial pulse you should look out for its rate and rhythm. Normal pulse rate is around 60-100 bpm (beats per minute).

A collapsing pulse is a strong pulse that drops away suddenly. It reflects a widened pulse pressure (the difference between the systolic and diastolic blood pressure), as in aortic regurgitation (a leaking aortic valve). In the collapsing pulse test, you will feel a ‘tapping’ sensation in the pulse when the arm is raised quickly above the head. Raising the arm makes the sign easier to feel. Before performing this test, it is important to ask if the patient is experiencing any shoulder pain.

To assess the character of the pulse use either the brachial or carotid artery. The pulse's character can be normal, bounding or thready. Other characters include a slow-rising pulse (seen in aortic stenosis, a narrowed aortic valve) and a collapsing pulse (see above).

A bounding pulse, when the pulse feels very strong and throbbing, can be caused by conditions such as aortic regurgitation or severe bradycardia (a slow heart rate). Fever, anaemia and thyrotoxicosis (an overactive thyroid gland) can also cause it. In aortic regurgitation, the pulse pressure is widened leading to a stronger feeling pulse. This is because the left ventricle ejects a larger than normal stroke volume (the volume of blood pumped out with each beat), which tends to raise the systolic pressure. In diastole, however, blood in the aorta runs back into the ventricle through the leaking (incompetent) valve, so the diastolic pressure is low. This results in a large difference between systolic and diastolic pressure, and the pressure changes can be felt as a bounding pulse. Bradycardia allows a longer time for the diastolic run off to occur. This widens the pulse pressure and increases the strength of the pulse.

A thready pulse, one that feels very weak, is seen in conditions when there is a low mean arterial blood pressure (the average pressure in the arteries over one heartbeat), such as in left ventricular failure or hypovolaemia (low blood volume).

Radio-radial delay is when the two radial pulses are not in sync with each other. This can be caused by coarctation of the aorta (narrowing) between the origins of the brachiocephalic trunk (the first branch of the aortic arch, which supplies the right arm and the right side of the head) and the left subclavian artery. This means that blood pumped out of the heart can easily pass through the brachiocephalic trunk. Blood travelling through the left subclavian must pass through the narrowed section. This causes a delay in the blood flow to the left arm. Therefore, the radial pulse in the left arm will be felt slightly after the pulse in the right arm. If the coarctation is after the left subclavian artery, the radial pulses will be felt to be in sync, but the femoral pulse will be delayed. This is called radio-femoral delay.

Radio-radial delay may also be caused by an aortic dissection (a tear in the wall of the aorta).

Brachial blood pressure should be monitored to assess for hypo- or hypertension by measuring blood pressure in the upper arm. Read our hypertension guide.

Image - Coarctation of the aorta. The coarctation is after the three branches of the aortic arch, so the patient will have radio-femoral delay on examination

SimpleMed original by Dr. Bethany Turner

On general inspection of the face, assess for mitral facies. This is a sign in which the patient has rosy cheeks with bluish patches. Some authors describe this simply as pinkish-purple patches on the cheeks. It occurs in patients with mitral stenosis (narrowing of the mitral valve) with associated reduced cardiac output.

Patients with hyperlipidaemia may have abnormalities in or around the eyes due to deposition of lipid. Corneal arcus is lipid deposition in the peripheral cornea, seen as a pale ring near the corneal margin. Corneal arcus is common with ageing. Before the age of 45 years, it should prompt assessment for dyslipidaemia (abnormal levels of fats in the blood), in particular familial hypercholesterolaemia. Xanthelasma is similar to tendinous xanthoma in that it is seen when lipid is deposited in the skin around the eyes. It is seen as small raised yellow patches of skin. It does not always mean the blood lipid levels are high: in one study, just over half of the people with xanthelasma had a normal cholesterol level.

Image - Xanthelasma. There are visible raised yellow patches of skin around the eyes

Creative commons source by Oleg Tymofii [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

When a patient pulls down their lower eyelids, look for paleness of the conjunctiva (the thin pink lining of the inner eyelid), which could indicate anaemia.

When assessing the mouth, central cyanosis may be seen, which is a bluish tinge to the mucous membranes. This indicates low oxygen saturation in the blood circulating around the body. Cardiovascular causes include cyanotic congenital heart defects (heart defects present from birth that let blood bypass the lungs) and pulmonary embolism. Do not confuse it with peripheral cyanosis, which is caused by poor circulation rather than poor oxygenation of the blood.

Anaemia from iron or vitamin B12 deficiency can cause glossitis or angular stomatitis. Glossitis (an inflamed tongue) is seen as a glossy, smooth tongue. In iron deficiency this is called atrophic glossitis. In vitamin B12 deficiency the tongue can also be sore and red. Angular stomatitis is seen as dry erythematous (red) changes to the skin at the corners of the mouth.

It is important to assess the state of the teeth (dentition) in a cardiovascular exam, as poor dental hygiene is a common route of entry for the bacteria that can cause infective endocarditis.

Image - Angular stomatitis, which can be a sign of iron deficiency anaemia

Creative commons source by Matthew Ferguson 57 [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Check the carotid pulses by placing your fingers on the side of the neck, between the sternocleidomastoid muscle (the large neck muscle that runs from behind the ear to the collarbone) and the trachea (windpipe), in the middle third of the neck. Assess the character of the pulse. Do not press high up under the jaw, because the carotid sinus lies there. Pressure on the carotid sinus can slow the heart rate and make the patient faint. Check one side at a time, because pressing on both together can also reduce blood flow to the brain.

Ask the patient to hold their breath and, using the bell of your stethoscope, listen over the carotid arteries for any carotid bruits (abnormal noises). A bruit could indicate narrowing of the carotid arteries, which is a risk factor for stroke. However, listening alone is not reliable: in one study, auscultation missed 44% of people with significant (60% or more) carotid narrowing. A bruit in the neck may also be due to a murmur (an extra sound caused by turbulent blood flow) from aortic stenosis (narrowing of the aortic valve) that radiates to the neck. A good tip is to hold your breath along with the patient. This ensures that the patient does not have to hold their breath for longer than is necessary. 

Assessing the jugular venous pressure (JVP) can give an indication about the pressure in the venous circulation. Pressure can be raised in conditions such as fluid overload or right sided heart failure. To perform the test, make sure the patient is sitting at 45° with their head turned to the left. Identify the internal jugular vein which usually lies between the two heads of the sternocleidomastoid muscle as it inserts into the sternum and clavicle.If a pulse is visible, measure the height between the sternal angle and the border of the pulsation to assess whether the pressure is raised.

Image - How to measure the JVP. Angle the patient at 45° and ask them to turn their head away from you and look for a pulsation in their neck. A pulsation more than 3 cm above the sternal angle suggests pathology such as fluid overload or heart failure

SimpleMed original by Dr. Bethany Turner

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