Why Cardiovascular Examination Is Examined Every Year
The cardiovascular examination is one of the most consistent OSCE stations across all UK medical schools. It tests the integration of technique, clinical reasoning, and communication. Common formats include:
- Normal examination — present findings and suggest differentials
- Murmur station — characterise a murmur and give the likely valve lesion
- Signs station — examine a patient with heart failure or AF
- Video OSCE — identify a sign and explain its significance
This guide covers the full examination with the clinical reasoning behind each step.
💡 Tip
At every examination station, start with: "I'd like to perform a cardiovascular examination. I'll need to expose your chest — is that okay?" This demonstrates consent, positions you correctly, and scores introductory marks before you've touched the patient.
The Sequence
End of bed → Hands → Face → Neck → Praecordium → Lung bases → Calves
Always work this sequence. Examiners follow it on the mark scheme.
1. End of Bed
Spend 5–10 seconds before touching the patient:
- Does the patient look well or unwell? Comfortable or breathless?
- Any monitoring equipment — oxygen, IV lines?
- Cachexia — suggests heart failure or malignancy
- Observe respiratory rate and use of accessory muscles
2. Hands
| Sign | What to look for | Clinical significance |
|---|---|---|
| Clubbing | Loss of nail angle; fluctuant nail bed | Infective endocarditis, cyanotic heart disease |
| Splinter haemorrhages | Linear red-brown lines under nails | Infective endocarditis (also trauma) |
| Osler's nodes | Tender red nodules on finger pads | Infective endocarditis |
| Janeway lesions | Non-tender haemorrhagic macules on palms | Infective endocarditis (septic emboli) |
| Peripheral cyanosis | Blue discolouration of fingers | Poor perfusion, cardiac failure |
| Xanthomata | Yellowish plaques over tendons | Hypercholesterolaemia |
Radial pulse: Rate, rhythm, character. Compare both sides simultaneously (radio-radio delay → aortic coarctation).
Capillary refill time: Press for 5 seconds — >2 seconds is prolonged.
💎 Clinical Pearl
When examining the radial pulse, simultaneously count the rate for 15 seconds (×4), assess regularity, and feel for radio-femoral delay (delayed femoral pulse suggests coarctation). Doing all three at once demonstrates clinical efficiency.
3. Face and Mouth
| Sign | What to examine | Clinical significance |
|---|---|---|
| Corneal arcus | White ring around iris | Hypercholesterolaemia (significant if <50 years) |
| Xanthelasma | Yellow periorbital plaques | Hyperlipidaemia |
| Conjunctival pallor | Pale inner eyelids | Anaemia |
| Central cyanosis | Blue tongue and buccal mucosa | Desaturated haemoglobin |
| High-arched palate | Marfan feature | Associated with aortic root dilatation, MVP |
| Malar flush | Rosy flush over cheeks | Mitral stenosis (classic, now uncommon) |
4. Neck — JVP
The jugular venous pressure is one of the most commonly examined and most commonly done poorly signs.
Position: Patient at 45°, head turned slightly away from you.
Which vein: The internal jugular — medial to sternocleidomastoid, soft, flickering, double pulsation. Not palpable (unlike the carotid).
Height: Measure vertically from the sternal angle (angle of Louis). Normal: ≤3–4 cm. Raised: ≥4 cm above sternal angle.
🧠 Mnemonic
JVP waveform:
- a wave: Atrial contraction (absent in AF)
- v wave: Venous filling while tricuspid closed
- x descent: Atrial relaxation
- y descent: Tricuspid opens, ventricle fills
Giant a wave → tricuspid stenosis, pulmonary hypertension
Giant v wave → tricuspid regurgitation
Absent a wave → atrial fibrillation
Hepatojugular reflux: Sustained pressure over the right upper quadrant for 15 seconds — a rise >3 cm = right heart failure.
Raised JVP suggests: right heart failure, cardiac tamponade (Beck's triad: raised JVP + hypotension + muffled heart sounds), SVC obstruction, fluid overload.
5. Praecordium
Inspection
- Sternotomy scar — CABG or valve replacement
- Left lateral thoracotomy — mitral valve surgery (historical)
- Visible apex beat — suggests cardiomegaly
- Chest deformity — pectus excavatum (associated with MVP, Marfan)
Palpation
Apex beat: Normally 5th intercostal space, mid-clavicular line.
| Character | Significance |
|---|---|
| Displaced laterally and downward | Cardiomegaly (dilated cardiomyopathy, MR, AR) |
| Heaving (sustained, thrusting) | LV pressure overload (AS, hypertension) |
| Tapping | Palpable S1 — mitral stenosis |
| Diffuse, difficult to localise | Dilated cardiomyopathy |
Thrills: Palpable murmurs (grade ≥4). State: "I can feel a systolic thrill at the upper right sternal edge."
Parasternal heave: Heel of right hand over left sternal edge — heaving forward = right ventricular hypertrophy (pulmonary hypertension).
Auscultation
| Area | Location | Valve heard best |
|---|---|---|
| Mitral | Apex (5th ICS, MCL) | Mitral |
| Tricuspid | Lower left sternal edge (4th ICS) | Tricuspid |
| Pulmonary | Upper left sternal edge (2nd ICS) | Pulmonary |
| Aortic | Upper right sternal edge (2nd ICS) | Aortic |
🧠 Mnemonic
All Patients Take Medicine — Aortic, Pulmonary, Tricuspid, Mitral.
Work: upper right → upper left → lower left → apex.
Heart sounds:
- S1 — mitral and tricuspid valve closure; onset of systole
- S2 — aortic and pulmonary valve closure; onset of diastole
- S3 — low-pitched, early diastole; pathological in adults (heart failure, MR)
- S4 — late diastole, before S1; stiff ventricle (hypertension, AS, HOCM)
6. Murmur Characterisation
If you hear a murmur, characterise it systematically:
- 1Timing — systolic or diastolic?
- 2Location — where is it loudest?
- 3Radiation — carotids? Axilla?
- 4Character — harsh, blowing, rumbling?
- 5Grade — Levine scale 1–6
- 6Manoeuvres — position, respiration
| Murmur | Character | Location | Radiation | Key feature |
|---|---|---|---|---|
| Aortic stenosis | Harsh ejection systolic | Upper right sternal edge | Carotids | Slow-rising pulse; heaving apex |
| Mitral regurgitation | Pansystolic, blowing | Apex | Axilla | Displaced apex; may have S3 |
| Aortic regurgitation | Early diastolic, blowing | Lower left sternal edge | — | Collapsing pulse; wide pulse pressure |
| Mitral stenosis | Mid-diastolic rumble | Apex | — | Tapping apex; opening snap |
| Tricuspid regurgitation | Pansystolic | Lower left sternal edge | — | Louder in inspiration (Carvallo's sign) |
💎 Clinical Pearl
The two most common OSCE murmurs: aortic stenosis and mitral regurgitation. Know these cold. AS: elderly, ejection systolic, radiates to carotids, slow-rising pulse, heaving apex. MR: pansystolic, radiates to axilla, displaced apex, possible S3.
7. Complete the Examination
- Lung bases: bibasal crackles = pulmonary oedema (left heart failure)
- Sacral oedema: check in any patient in bed — the most dependent site
- Ankle oedema: pitting = right or biventricular failure, hypoalbuminaemia
How to Present Your Findings
"On examination, general inspection revealed [peripheral signs]. The pulse was [rate], [regular/irregular], [character]. The JVP was [not raised / raised X cm]. The apex beat was in the [position] and was [character]. Heart sounds: S1 and S2 were [normal]; I [could / could not] hear an S3 or S4. There was [a murmur characterised by...] / [no murmur]. The lung bases were [clear / bibasal crackles]. There was [no / pitting] oedema. In summary, these findings are consistent with [diagnosis], and I would like to confirm with [investigations]."
Common Examiner Follow-Up Questions
"You've found a pansystolic murmur at the apex radiating to the axilla — what's your diagnosis and how would you investigate?"
"This is most consistent with mitral regurgitation. I would confirm with an echocardiogram to assess valve anatomy, regurgitant fraction, and LV function. I'd also do an ECG and CXR for left atrial enlargement, LV hypertrophy, and pulmonary oedema."
"The patient has a raised JVP and bibasal crackles — what's the most likely diagnosis?"
"This is consistent with biventricular cardiac failure. I would investigate with BNP, echocardiogram, ECG, CXR, and renal function, and manage with diuresis."
"What is the difference between S3 and S4?"
"S3 occurs in early diastole when rapid ventricular filling produces turbulence — it is pathological in adults and suggests heart failure or a volume-overloaded ventricle such as in mitral regurgitation. S4 occurs in late diastole due to atrial contraction against a stiff ventricle — it suggests reduced ventricular compliance from hypertension, aortic stenosis, or hypertrophic cardiomyopathy."