Cardiovascular Examination

The routine

• Introduce, explain, glance from end of bed
• Say "Could you hold out your hands please"
• Inspect nails for clubbing, splinter haemorrhages. Press on the nails for capillary refill time. Say, "could you turn your hands over" and feel for temperature.
• Feel the radial pulses of both hands initially. Then feel for femoro-radial delay. Finally record the pulse for 15s, and then the respiratory rate for 15s. Aortic stenosis has a slow rising pulse character.
• Say "Do you have any pain or stiffness in your shoulder, would you mind if I lifted your arm up?" Hold the arm with your left hand at the radial pulse, and right hand at the elbow and lift the arm up above the patient's head. Aortic regurgitation gives a collapsing pulse character.
• Say "would you like me to measure the blood pressure" to the examiner

Head and neck

• Look in the eyes. Pull down one lid for conjunctival pallor (anaemia). Look in the mouth for central cyanosis
• Say "could you turn your head to the left" and look to see if the venous pressure is raised
• Carotid pulse with finger tips

Praecordium

• Expose the praecordium. If this is a women you will be expected to remove her bra.
• Inspect for scars (midline, left or right thoracotomy). If seen check for scars on the arms and legs to see if veins have been stripped for a CABG (if not is this scar for a valve repair?)
• Palpate the apex beat: start lateral and inferior to where it should be (5th intercostal space, midclavicular line) and work in until found. Then count down ribs to see if it is displaced. Note its nature (e.g. tapping)
• Feel for heaves with the bottom half of your palm, either side of the lower sternum. Feel for thrills with the palmer side of your fingers either side of the upper sternum
• Say "Can you roll to your left." Re-palpate the apex beat
• Auscultate the apex beat with the bell and the diaphragm.
• Get the patient rolled back, then auscultate all other valve areas with just the diaphragm. The valve areas are illustrated in the illustration below. A useful mnemonic is "All Prostitutes Take Money" for Aortic, Pulmonary, Tricuspid, Mitral valve areas going from left to right upper then lower chest. Auscultate the carotids for bruits and radiation.
• The murmur of aortic stenosis is loudest at the right sternal edge 2nd intercostal space and sometimes radiates to the carotids, it is termed ejection systolic because of its increasing and then decreasing volume in systole. The murmur of mitral regurgitation is loudest at the apex beat and is termed pansystolic because it is of equal volume throughout systole. The murmur of mitral stenosis occurs over the apex beat during the end of diastole, and is "rumbling" in character.
• Say "would you mind leaning forward. When I tell you to do so, could you take a deep breath in and then blow it all the way out and hold it." Place your diaphragm over the 5th intercostal space left sternal edge, and then then get them to perform the breathing manouvre and hold their breath. Listen for aortic regurgitation.
• Keep them sat forward. Now auscultate their back at the lung bases for crackles. Press down on their sacrum for sacral oedema

Other

• Expose their legs and inspect them (see the vascular examination). Palpate the popliteal, posterior malleolar and dorsalis pedis pulses. Press on their shins for at least 3s for ankle oedema.

"I would like to"

• Examine the abdomen for hepatomegaly (portal venous congestion in congestive cardiac failure)
• Look at the temperature chart (endocarditis)
• Look at the fundi (hypertension, diabetes)

Common Conditions for OSCEs

Probably the commonest OSCE station of them all.

1. Valvular heart disease: Usually systolic murmurs. The commonest are mitral regurgitation and aortic stenosis
2. Prosthetic valves
3. Heart failure
4. Atrial fibrillation

Presenting

Present the positive findings, and the relevant negatives. The examiner has seen you examine the patient so he knows that you know that you should look at the nails, but he doesn't want to hear about it if you didn't find anything (he has also examined the patient). For example:

• This is Mr Jones, he is a gentleman who looks comfortable at rest. 
• His pulse is 70, irregularly irregular. He is not tachypnoeic. His blood pressure is 140/80. 
• He has a malar flush. He venous pressure is raised and he has ankle oedema. There are no other peripheral stigmata of disease.
• His apex beat is undisplaced but tapping. He has a mid-diastolic murmur at the apex accentuated in the left lateral position.
• My diagnoses is atrial fibrillation and mitral stenosis, causing congestive cardiac failure. There are no features of endocarditis.

Internet Resources

• Research shows the best way to recognise heart murmurs is to put them on your ipod and keep replaying them ( Barrett et al. Mastering cardiac murmurs: the power of repetition. Chest, 2005 ). If you feel like doing this then you can download the files from the Texas Heart Institute as well as eGeneralMedical .