Cardiology Examination

Question 1

What should you do at the start of the station

Answer 1

Wash Hands
Introduce yourself
Patient details
Explain procedure

Gain consent

Ensure patient is not in any chest pain/experiencing a crushing weight on their chest

Ensure patient is comfortable and in hot environment.

Question 2

Which angle should the bed be placed at for the purpose of the cardiology exam

Answer 2

45 degrees

Question 3

Which parts of the patient should be exposed for the purpose of the cardiology exam

Answer 3

Adequately expose the patient’s chest for the examination (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema and signs of peripheral vascular disease.

Explain that in order to hear and see the chest clearly- needs to be undressed from the shoulders to the hip- no need to remove bra- make patient aware that examiner will act as the chaperone.

Question 4

What clinical signs should you look for in general inspection

Answer 4

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

Cyanosis: a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath: may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a healthy individual may have a pale complexion that mimics pallor, however, pathological causes should be ruled out.
Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis.
Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit.

Also look for scarring

Question 5

Describe the medical paraphernalia pertinent to the cardiovascular system that you should look for upon general inspection

Answer 5

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

Medical equipment: note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Pillows: patients with congestive heart failure typically suffer from orthopnoea, preventing them from being able to lie flat. As a result, they often use multiple pillows to prop themselves up.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.

Question 6

Describe the general observations of the hand

Answer 6

General observations

Inspect the hands for clinical signs relevant to the cardiovascular system:

Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.

Question 7

Describe finger clubbing

Answer 7

Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).

To assess for finger clubbing:

Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window)
When finger clubbing develops, this window is lost.

Question 8

Describe the stigmata in the hand associated with endocarditis

Answer 8

Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis

Question 9

What should you palpate on the hands in the cardiology examination

Answer 9

Temperature

Place the dorsal aspect of your hand onto the patient’s to assess temperature:

In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Capillary refill time (CRT)

Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:

Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Question 10

How do you measure the radial pulse in OSCE

Answer 10

Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm

Question 11

How do you assess heart rate in OSCE

Answer 11

Assessing heart rate:

You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.

Question 12

Describe how to interpret normal and abnormal heart rates

Answer 12

Normal and abnormal heart rates

In healthy adults, the pulse should be between 60-100 bpm.
A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome).
A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism).
An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.

Question 13

How do we asses for the radio-radial delay

Answer 13

Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.

To assess for radio-radial delay:

Palpate both radial pulses simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the radial pulses are out of sync, this would be described as radio-radial delay.

Question 14

What are the causes of a radio-radial delay

Answer 14

Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation

Question 15

What is a collapsing pulse

Answer 15

A collapsing pulse is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.

Question 16

How do we assess for the collapsing pulse

Answer 16

Ask the patient if they have any pain in their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided).
Palpate the radial pulse with your right hand wrapped around the patient’s wrist.
Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow.
Raise the patient’s arm above their head briskly.
Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole.

Question 17

What are the causes of a collapsing pulse

Answer 17

Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)

Question 18

Describe the physiological water hammer pulse

Answer 18

In physiological and hyperdynamic circulatory states, the fall in systemic vascular resistance and increased cardiac output causes the water hammer pulse.

Question 19

Describe the pathophysiological water hammer pulse

Answer 19

The pathophysiology in patients with aortic regurgitation is different. An increased stroke volume filling the relatively empty arterial vessels causes the rapid upstroke when feeling the water hammer pulse. This increased stroke volume is secondary to an increase in end-diastolic volume from the retrograde blood flow from the aorta into the left ventricle during ventricular diastole, or relaxation. The rapid downstroke is partly due to two causes. The first cause is the sudden fall in diastolic pressure in the aorta, which is due to regurgitation of blood from the aorta, or “aortic run-off,” into the left ventricle through the leaky valve. The second cause is the rapid emptying of the arterial system.

Question 20

What are the other signs of atrial regurgitation

Answer 20

The decrease in diastolic pressure from the regurgitant flow also causes an increase in pulse pressure. Pulse pressure is the difference between the systolic and diastolic pressure. Compensation for the decrease in diastolic pressure occurs in two ways. First, due to the regurgitant fraction of blood flow, the heart undergoes chamber dilation and eccentric hypertrophy. These effects increase the stroke volume and therefore the systolic pressure. Secondly, the sympathetic nervous system releases catecholamines and the renin-angiotensin-aldosterone axis works to increase cardiac output to try to maintain a normal mean arterial pressure. As aortic regurgitation continues to progress and worsen, the systolic pressure and pulse pressure continue to rise. Increasing these pressures accentuates the water hammer pulse. However, as the left ventricle continues to stretch, and with the resultant cardiac remodeling, systolic heart failure eventually develops. Systolic heart failure results in stroke volume decrease and forward blood flow

Question 21

Describe how we palpate the brachial pulse

Answer 21

Palpate the brachial pulse

Palpate the brachial pulse in their right arm, assessing volume and character:

1. Support the patient’s right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus. Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.

Question 22

What are the different types of pulse character

Answer 22

Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)

Question 23

Describe how we measure the blood pressure

Answer 23

Measure the patient’s blood pressure in both arms (see our blood pressure guide for more details).

A comprehensive blood pressure assessment should also include lying and standing blood pressure.

In a cardiovascular examination OSCE station, you are unlikely to have to carry out a thorough blood pressure assessment due to time restraints, however, you should demonstrate that you have an awareness of what this would involve.

Question 24

Describe blood pressure abnormalities

Answer 24

Blood pressure abnormalities may include:

Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
Hypotension: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.

Question 25

Where is the carotid pulse located

Answer 25

The carotid pulse can be located between the larynx and the anterior border of the sternocleidomastoid muscle.

Question 26

What should be done before palpating the carotid pulse

Answer 26

Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.

Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.

Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).

Question 27

Describe palpation of the carotid pulse

Answer 27

If no bruits were identified, proceed to carotid pulse palpation:

1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).
2. Gently place your fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.
3. Assess the character (e.g. slow-rising, thready) and volume of the pulse.

Question 28

What are bruits signs of

Answer 28

Arterial narrowing- may indicate risk of stroke

Question 29

What is the JVP a measure of

Answer 29

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).

Question 30

Where is the IJV located

Answer 30

The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle).

Question 31

Why is the EJV a less reliable indicator than the IJV

Answer 31

Because of the inability to easily visualise the IJV, it’s tempting to use the external jugular vein (EJV) as a proxy for assessment of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous pressure.

Question 32

How do we assess for the JVP

Answer 32

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).

Question 33

What are the causes of a raised JVP

Answer 33

A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include:

Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Question 34

Describe how we elicit the hepatojugular reflex

Answer 34

To be able to perform the test, there should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible:

Position the patient in a semi-recumbent position (45º).
Apply direct pressure to the liver.
Closely observe the IJV for a rise.
In healthy individuals, this rise 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 deemed a positive result.
This assessment can be uncomfortable for the patient and therefore it should only be performed when felt necessary (an examiner will often prevent you from performing it in an OSCE but you should mention it).

Question 35

How do we observe the height of the JVP

Answer 35

Observe the patient at 45°, with their head turned slightly to the left and neck relaxed. Good lighting and correct positioning are key. Look for the right internal jugular vein as it passes just medial to the clavicular head of the sternocleidomastoid up behind the angle of the jaw to the earlobes. The jvp is assessed by measuring the vertical height from the manubriosternal angle (not the sternal notch) to the top of the pulse. Pressure at zero (at the sternal angle) is 5cm, so add the height of the jvp with 5cm to obtain the right heart filling pressure in cm of water. A pressure above 9cm (4cm above the sternal angle at 45°) is elevated.

Question 36

How do we distinguish between the jvp and the carotid pulse

Answer 36

• Usually impalpable, and obliterated by finger pressure on the vessel.
• Rises transiently with pressure on abdomen (abdominojugular reflux)2 or on liver (hepatojugular reflux), and alters with posture and respiration (disappears when patient sits from lying flat).
• Usually has a double pulse for every arterial pulse.

Question 37

Describe the anatomy of the JVP wave

Answer 37

A wave- atrial systole

C wave- closure of tricuspid wave- not normally visible

x decent- fall in atrial pressure during ventricular systole

v wave- atria filling against a closed tricuspid

y decent- opening of tricuspid valve

Question 38

What happens to the JVP in the x decent

Answer 38

The jugular venous pressure wave. The jvp drops as the x descent during ventricular systole because the right atrium is no longer contracting. This means that the pressure in the right atrium is dropping and this is reflected by the jvp.

Question 39

Summarise the abnormalities of the JVP

Answer 39

• Raised jvp with normal waveform: Fluid overload, right heart failure.
• Fixed raised jvp with absent pulsation: svc obstruction (p[link]).
• Large a wave: Pulmonary hypertension, pulmonary stenosis.
• Cannon a wave: When the right atrium contracts against a closed tricuspid valve, large ‘cannon’ a waves result. Causes—complete heart block, single chamber ventricular pacing, ventricular arrhythmias/ectopics.
• Absent a wave: Atrial fibrillation.
• Large v waves: Tricuspid regurgitation—look for earlobe movement.
• Constrictive pericarditis: High plateau of jvp (which rises on inspiration—Kussmaul’s sign) with deep x and y descents.
• Absent jvp: When lying flat, the jugular vein should be filled. If there is reduced circulatory volume (eg dehydration, haemorrhage) the jvp may be absent.

Question 40

What are the abnormalities associated with the hepatojugular reflux

Answer 40

A positive hepatojugular reflux result suggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition. The following conditions frequently produce a positive hepatojugular reflux test:

Constrictive pericarditis
Right ventricular failure
Left ventricular failure
Restrictive cardiomyopathy

Question 41

What signs in the eyes are relevant to the CVS

Answer 41

Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).

Question 42

Describe the signs in the mouth that are relevant to the CVS

Answer 42

Central cyanosis: bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
Dental hygiene: poor dental hygiene is a risk factor for infective endocarditis.

Question 43

Describe close inspection of the chest

Answer 43

Look for clinical signs that may provide clues as to the patient’s past medical/surgical history:

Scars suggestive of previous thoracic surgery: see the thoracic scars section below.
Pectus excavatum: a caved-in or sunken appearance of the chest.
Pectus carniatum: protrusion of the sternum and ribs.
Visible pulsations: a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.

Question 44

Describe the different thoracic scars

Answer 44

Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

Question 45

What is meant by the apex beat

Answer 45

o Apex Beat definition: the most lateral and inferior position where the cardiac impulse can be felt
• It occurs due to the heart rotating and moving forward and striking against the chest wall
• Position of the apex beat: Left 5th intercostal space, mid-clavicular line

Question 46

Describe how to palpate the apex beat

Answer 46

Palpate the apex beat with your fingers placed horizontally across the chest.
In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant.
Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy

Question 47

Describe heaves

Answer 47

A parasternal heave is a precordial impulse that can be palpated.
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
If heaves are present you should feel the heel of your hand being lifted with each systole.
Parasternal heaves are typically associated with right ventricular hypertrophy.

Question 48

Describe thrills

Answer 48

A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
You should assess for a thrill across each of the heart valves in turn (see valve locations below).
To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed

Question 49

Summarise the differences between thrills and heaves

Answer 49

• Thrills
 A bubbling feeling under the hand when it is placed on the chest
 Thrills are palpable murmurs
 Common causes include aortic stenosis
• Heaves
 The chest feels like it is rising up when the heart beats
 Caused by ventricular hypertrophy

Question 50

Describe the locations of the heart valves

Answer 50

Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge

Question 51

Summarise auscultation of the heart valves

Answer 51

A systematic routine will ensure you remember all the steps whilst giving you several chances to listen to each valve area. Your routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps. Ask the patient to lift their breast to allow auscultation of the appropriate area if relevant.

Question 52

Describe auscultation of the heart valves

Answer 52

1. Palpate the carotid pulse to determine the first heart sound.
2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the carotid pulse:

Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
3. Repeat auscultation across the four valves with the bell of the stethoscope

Question 53

Describe the accentuation manoeuvres for murmurs

Answer 53

4. Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis.
5. Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.
6. Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
7. With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.

Question 54

Compare the bell vs diaphragm for auscultating murmurs

Answer 54

The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.

The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.

Question 55

What happens to the loudness of aortic and mitral murmurs upon expiration

Answer 55

They get louder

Question 56

Describe auscultion and inspection of the posterior chest wall

Answer 56

Inspection

Inspect the posterior chest wall for any deformities or scars (e.g. posterolateral thoracotomy scar associated with previous lung surgery).

Auscultation

Auscultate the lung fields posteriorly:

Coarse crackles are suggestive of pulmonary oedema (associated with left ventricular failure).
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural effusion (associated with left ventricular failure).

Question 57

Describe how we assess for sacral oedema

Answer 57

Inspect and palpate the sacrum for evidence of pitting oedema.

Question 58

Describe how we assess for leg oedema

Answer 58

Inspect and palpate the patient’s ankles for evidence of pitting pedal oedema (associated with right ventricular failure).

Inspect the patient’s legs for evidence of saphenous vein harvesting (performed as part of a coronary artery bypass graft).

Question 59

How should we end the exam

Answer 59

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Wash your hands.

Summarise your findings

Question 60

Give an example summary

Answer 60

“Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest and there were no objects or medical equipment around the bed of relevance.”

“The hands had no peripheral stigmata of cardiovascular disease and were symmetrically warm, with a normal capillary refill time.”

“The pulse was regular and there was no radio-radial delay. On auscultation of the carotid arteries, there was no evidence of carotid bruits and on palpation, the carotid pulse had normal volume and character.”

“On inspection of the face, there were no stigmata of cardiovascular disease noted in the eyes or mouth and dentition was normal.”

“Assessment of the JVP did not reveal any abnormalities and the hepatojugular reflux test was negative.”

“Closer inspection of the chest did not reveal any scars or chest wall abnormalities. The apex beat was palpable in the 5th intercostal space, in the mid-clavicular line. No heaves or thrills were noted.”

“Auscultation of the praecordium revealed normal heart sounds, with no added sounds.”

“There was no evidence of peripheral oedema and lung fields were clear on auscultation.”

“In summary, these findings are consistent with a normal cardiovascular examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

Question 61

What further investigations should be completed

Answer 61

Suggest further assessments and investigations to the examiner:

Measure blood pressure: to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection.
Peripheral vascular examination: to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology.
Record a 12-lead ECG: to look for evidence of arrhythmias or myocardial ischaemia.
Dipstick urine: to identify proteinuria or haematuria which can be associated with hypertension.
Bedside capillary blood glucose: to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease.
Perform fundoscopy: if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema.