cmecde 65

 

Cardiovascular and respiratory medicine

Station 17 Respiratory system examination 43

• Examine the lymph nodes from behind with the patient sitting up. Have a systematic routine

for examining all of the submental, submandibular, parotid, pre- and post-auricular, occipital,

anterior cervical, posterior cervical, supra- and infra-clavicular, and axillary lymph nodes (see

Station 9).

• Palpate for tracheal deviation by placing the index and middle fingers of one hand on either

side of the trachea in the suprasternal notch. Alternatively, place the index and annular fingers

of one hand on either clavicular head and use your middle finger (called the Vulgaris in Latin)

to palpate the trachea.

Palpation of the chest

Ask the patient if he has any chest pain.

• Inspect the chest more carefully, looking for asymmetries, deformities, and scars.

• Inspect the precordium and palpate for the position of the cardiac apex. Difficulty palpating for

the position of the cardiac apex may indicate hyperexpansion, although this is not a specific

sign.

[Note] Carry out all subsequent steps on the front of the chest and, once finished, repeat them on the back of the chest.

This is far more elegant than to keep asking the patient to bend forwards and backwards like a Jack-in-the-box.

Pulmonary anatomy is such that examination of the back of the chest yields information about the lower lobes,

whereas examination of the front of the chest yields information about the upper lobes and, on the right-side,

also the middle lobe (Figure 10).

• Palpate for equal chest expansion, comparing one side to the other. Reduced unilateral chest

expansion might be caused by pneumonia, pleural effusion, pneumothorax, and lung col lapse.

If there is a measuring tape, measure the chest expansion.

Figure 10. A right lateral view demonstrating lobar

anatomy. Posterior assessment gives information

about the lower lobes, whereas examination from

the front looks at the upper and middle lobes (the

latter only on the right).

Upper lobe

Lower lobe

Middle lobe

Clinical Skills for OSCEs

44 Station 17 Respiratory system examination

Percussion of the chest

• Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not

forget to percuss over the clavicles and on the sides of the chest. For any one area, is the resonance increased or decreased? A hyper-resonant or tympanic note may indicate emphysema

or pneumothorax, whereas a dull or stony dull note may indicate consolidation, fibrosis, fluid,

or lung collapse. If you uncover any variation in the percussion note, be sure to map out its

geographical extent.

• Test for tactile fremitus by placing the flat of the hands on the chest and asking the patient to

say “ninety nine”.

Auscultation of the chest

• Ask the patient to take deep breathsthrough the mouth and, using the diaphragm of the stethoscope, auscultate the chest in the same locations as for percussion. Start at the apex of one

lung, in the supraclavicular fossa, and compare one side to the other. Normal breath sounds

are described as ‘vesicular’ and have a low pitched and rustling quality. Reduced breath sounds

may indicate consolidation. Listen carefully for added sounds such as wheezes (rhonchi), crackles (crepitations), bronchial breathing, and pleural friction rubs.

• Test for vocal resonance by asking the patient to say “ninety nine”. Both consolidation and

pleural effusions can lead to a dull percussion note, but in consolidation vocal resonance is

increased whereas in pleural effusion it is decreased. Both vocal resonance and tactile fremitus

(see above) provide the same sort of information.

Inspection and examination of the legs

• Inspect the legs for erythema and swelling. Palpate for tenderness and pitting oedema. A

unilateral red, swollen, and tender calf suggests a DVT, whereas bilateral swelling may indicate

right-sided heart failure.

Figure 11. Palpating for equal chest expansion: upper, middle and lower lobes.

Cardiovascular and respiratory medicine

Station 17 Respiratory system examination 45

After the examination

• Indicate that you would look at the observations chart, examine a sputum sample, measure the

peak expiratory flow rate, and order some simple investigations such as a chest X-ray and a full

blood count.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Wash your hands.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a respiratory system examination station

Chronic obstructive pulmonary oedema (COPD):

• Signs may include breathlessness, breathing through pursed lips, cough, hyperinflated chest,

cyanosis, warm hands, tar staining, asterixis, bounding pulse, rhonchi, reduced breath sounds,

signs of right heart failure (cor pulmonale).

Cryptogenic fibrosing alveolitis:

• Signs may include breathlessness, dry cough, cyanosis, clubbing, reduced chest expansion,

fine late inspiratory crackles, signs of right heart failure (cor pulmonale).

Lobectomy

• Look carefully for a scar and listen for reduced or absent breath sounds.

Clinical Skills for OSCEs

46 Station 18

PEFR meter explanation

Read in conjunction with Station 116: Explaining skills.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Check his understanding of asthma and of the PEFR meter.

• Explain the importance of using a PEFR (Peak Expiratory Flow Rate) meter and the importance

of using it correctly.

• Explain that the PEFR meter is to be used first thing in the morning and at any time he has

symptoms of asthma.

Explain the use of a PEFR meter

Demonstrate and ask the patient to:

• Attach a clean mouthpiece to the meter.

• Slide the marker to the bottom of the numbered scale.

• Stand or sit up straight.

• Hold the peak flow meter horizontal, keeping his fingers away from the marker.

• Take as deep a breath as possible and hold it.

• Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece.

• Exhale as hard as possible into the meter.

• Read and record the meter reading.

• Repeat the procedure three to six times, recording only the highest score.

• Check this 21score against the peak flow chart or his previous readings.

• Check the patient’s understanding by asking him to carry out the procedure.

• Ask him if he has any questions or concerns.

Cardiovascular and respiratory medicine

Station 18 PEFR meter explanation 47

Interpret a PEFR reading

Figure 12. Expected peak flow rates in litres per minute according to age, sex, and height.

If the patient has been given a diary or chart to track PEFR variation:

• Explain that he must record a reading (best of three attempts) in the morning, afternoon, and

evening.

• Show him how to plot readings on the chart.

Height

Men

190 cm

183 cm

175 cm

cmecde 569

 

Oedema (non-pitting)

Venous ulcers

Varicose veins

Scars due to varicose vein surgery

Trendelenburg test

Perthes’ test (if after the gold medal)

[Note] The 6 Ps of limb ischaemia: pain, pallor, pulselessness, paraesthesia, paralysis, and perishingly cold.

Clinical Skills for OSCEs

36 Station 15

Ankle-brachial pressure index (ABPI)

Specifications: You are most likely to be requested to measure the ABPI for one arm and ankle only.

Calculating and interpreting ABPI

Figure 8. Calculating ABPI.

Table 7. ABPI interpretation

ABPI Interpretation

> 0.95

0.5–0.9

< 0.5

< 0.2

Normal

Claudication pain

Rest pain

Ulceration and gangrene

Higher of the two right ankle pressures

Higher of the two arm pressures

Higher of the two left ankle pressures

Higher of the two arm pressures

Right arm

systolic pressure

Left arm

systolic pressure

Right ankle

systolic

pressure

Left ankle

systolic

pressure

Posterior tibial

Dorsalis pedis

Posterior tibial

Dorsalis pedis

Right ABPI Left ABPI

Cardiovascular and respiratory medicine

Station 15 Ankle-brachial pressure index (ABPI) 37

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Position him at 45° with his sleeves and trousers rolled up.

• Ensure that he is comfortable.

• Wash your hands.

• State that you would allow him 5 minutes resting time before taking measurements.

The procedure

Brachial systolic pressure

• Place an appropriately sized cuff around the arm, as for any blood pressure recording.

• Locate the brachial pulse by palpation and apply contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff and record the pressure at which the signal reappears.

• Repeat the procedure for the other arm or state that you would do so.

• Retain the higher of the two readings.

Take care not to allow the probe to slide away from the line of the artery.

Ankle systolic pressure

• Place an appropriately sized cuff around the ankle immediately above the malleoli.

• Locate the dorsalis pedis pulse by palpation or with the hand-held Doppler probe and apply

contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff, and record the pressure at which the signal reappears.

• Repeat the procedure for the posterior tibial pulse, which is posterior and inferior to the medial

malleolus.

• Repeat the procedure for the dorsalis pedis and posterior tibial pulses of the other ankle orstate

that you would do so.

• For each ankle, retain the higher of the two readings.

After the procedure

• Clean the patient’s skin of contact gel and allow him time to restore his clothing.

• Clean the hand-held Doppler probe of contact gel.

• Wash your hands.

• Calculate the ABPI and explain its significance to the patient.

• Ask the patient if he has any questions or concerns.

• Thank the patient.

Clinical Skills for OSCEs

38 Station 16

Breathlessness history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the nature of his breathlessness, and obtain his consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint

• Ask about the nature of the breathlessness. Use open questions.

• Elicit the patient’s ideas, concerns and expectations (ICE).

History of presenting complaint

Ask about:

• Onset, duration, and variability of breathlessness.

• Provoking and relieving factors. Provoking factors include stress, exercise, cold weather, pets,

dust, and pollen; relieving factors include rest and use of inhaler or GTN spray.

• Severity:

– exercise tolerance: “How far can you walk before you get breathless? How far could you walk

before?”

– sleep disturbance: “Do you get more breathless when you lie down? How many pillows do you

use?”

– paroxysmal nocturnal dyspnoea: “Do you wake up in the middle of the night feeling breathless?”

• Associated symptoms(wheeze, cough,sputum, haemoptysis, fever, nightsweats, anorexia, loss

of weight, lethargy, chest pain, dizziness, pedal oedema).

• Effect on everyday life.

• Previous episodes of breathlessness.

• Smoking and alcohol.

Past medical history

• Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever),

PE/DVT, pneumonia, bronchitis, and tuberculosis.

• Previous investigations (e.g. bronchoscopy, chest X-ray).

• Previous hospital admissions and previous surgery.

Drug history

• Prescribed medication (especially bronchodilators, NSAIDs, b-blockers, ACE inhibitors,

amiodarone, and steroids) and route (e.g. inhaler, home nebuliser).

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Cardiovascular and respiratory medicine

Station 16 Breathlessness history 39

Family history

• Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic

fibrosis, tuberculosis, and emphysema (a1-antitrypsin deficiency).

Social history

• Smoking: 1 pack year is equivalent to 20 cigarettes per day for 1 year.

• Recent long-haul travel.

• Exposure to tuberculosis.

• Contact with asbestos (mesothelioma).

• Contact with work-place allergens involved in, for example, baking, soldering, spray painting.

• Contact with animals, especially cats, dogs, and birds (bird fancier’s lung).

After taking the history

• Ask the patient if there is anything else he might add that you have forgotten to ask.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to examine the patient and carry out some investigations to confirm

your diagnosis.

Conditions most likely to come up in a breathlessness history station

Asthma:

• Breathlessness, chest tightness, wheezing and coughing.

• Symptoms worse at night and in the early morning, and exacerbated by irritants, cold air,

exercise, and emotion.

• Symptoms respond to bronchodilators.

• There may be a history and family history of atopy.

Chronic obstructive pulmonary disease:

• Breathlessness, cough, wheeze.

• Chronic progressive disorder characterised by fixed or only partially reversible airway

obstruction (cf. asthma).

• History of smoking.

Pneumonia:

• Breathlessness accompanied by fever, cough, and yellow sputum, and in some cases by

haemoptysis and pleuritic chest pain.

Clinical Skills for OSCEs

40 Station 16 Breathlessness history

Tuberculosis:

• Breathlessness, cough, haemoptysis, weight loss, malaise, fever, night sweats, pleural pain,

symptoms of extrapulmonary disease.

• More likely in certain high-risk groups such as immigrants, the homeless and the

immunocompromised.

Pulmonary embolism:

• Breathlessness, sometimes with pleural pain and haemoptysis.

• There may be predisposing factors such as recent surgery, immobility, or long-haul travel.

Lung cancer:

• Symptoms may include breathlessness, stridor, cough, haemoptysis, anorexia, weight loss,

lethargy, pleural pain, hoarseness, Horner’s syndrome, effects of distant metastases.

• History of smoking in most cases.

Heart failure:

• Left ventricular failure leads to pulmonary oedema.

• Symptoms include breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, pedal

oedema.

• There is a cough which produces pink frothy sputum.

Panic attack:

• Rapid onset of severe anxiety lasting for about 20–30 minutes.

• Associated with chest tightness and hyperventilation.

41Cardiovascular and respiratory medicine

Station 17

Respiratory system examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45°, and ask him to remove his top(s).

• Ask him if he is in any pain or distress.

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health, nutritional status, and any other obvious signs). In particular, is he visibly breathless or cyanosed?

Does he have to sit up to breathe? Is his breathing audible? Are there any added sounds(cough,

wheeze, stridor)?

• Note:

– the rate, depth, and regularity of his breathing

– any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine

– any asymmetry of chest expansion

– the use of accessory muscles of respiration and planting of hands

– the presence of operative scars, including in the axillae and around the back

• Next observe the surroundings. Is the patient on oxygen? If so, note the device (see Tables 40

and 41 in Station 113), the concentration (%), and the flow rate. Look in particular for inhalers,

nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there

is a sputum pot, make sure to inspect its contents.

Inspection and examination of the hands

• Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated

by a bluish discoloration of the fingertips.

• Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less

than 2 seconds for the nail bed to return to its normal colour.

• Look fortarstaining and finger clubbing. When the dorsum of a fingerfrom one hand is opposed

to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s

window) is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is

obliterated, and a distal angle is created between the fingers (see Figure 9). Respiratory causes

of clubbing include carcinoma, fibrosing alveolitis, and chronic suppurative lung disease (see

Table 8).

• Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an

apical lung tumour that is invading or compressing the roots of the brachial plexus.

• Test for asterixis (see Table 9), the coarse flapping tremor of carbon dioxide retention, by asking

the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards.

Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine

tremor may be related to excessive use of B2 agonist.

• During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the

bounding pulse of carbon dioxide retention?

• Indicate that you would like to measure the blood pressure.

Clinical Skills for OSCEs

42 Station 17 Respiratory system examination

Table 8. The principal causes of clubbing

Respiratory causes

Bronchial carcinoma

Fibrosing alveolitis

Chronic suppurative lung disease

Cardiac causes

Infective endocarditis

Cyanotic heart disease

Gastrointestinal causes

Cirrhosis

Ulcerative colitis

Crohn’s disease

Coeliac disease

Familial

Table 9. The principal causes of asterixis

Hepatic failure

Renal failure

Cardiac failure

Respiratory failure

Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia)

Drug intoxication, e.g. alcohol, phenytoin

CNS causes

Inspection and examination of the head and neck

• Inspect the patient’s eyes. Look for a ptosis (an upper lid that encroaches upon the pupil) and

for anisocoria (pupillary asymmetry). Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis

are strongly suggestive of Horner’s syndrome, which may result from compression of the sympathetic chain by an apical lung tumour.

• Next inspect the sclera and conjunctivae for signs of anaemia.

• Ask the patient to open his mouth and inspect the underside of the tongue for the blue discoloration of central cyanosis.

• Assess the jugular venous pressure (JVP) and the jugular venous pulse form (see Station 13). A

raised JVP is suggestive of right-sided heart failure.

Figure 9. Clubbing. When the dorsum of a finger from one hand is opposed to the dorsum of a finger from the

other hand, a diamond-shaped window is formed at the base of the nailbeds. In clubbing, this diamond-shaped

window is obliterated, and a distal angle is created between the fingers.

cmecde 632

 

33Cardiovascular and respiratory medicine

Station 14

Peripheral vascular system examination

In this station you may be asked to restrict your examination to the arterial or venous system only. You

must therefore be able to separate out the signs for either (see Table 6).

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• After checking for any pain, ask him to expose his feet and legs and to lie down on the couch.

The examination

Inspection

• General appearance: body habitus, missing limbs or digits, surrounding paraphernalia such as

walking aids, oxygen, cigarettes.

• Skin changes: pallor, shininess, loss of body hair, atrophie blanche (ivory-white areas), haemosiderin ­pigmentation, inflammation, eczema, lipodermatosclerosis.

• Thickened dystrophic nails.

• Scars.

• Signs of gangrene: blackened skin, nail infection, amputated toes.

• Venous and arterial ulcers. Remember to look in the interdigital spaces.

• Oedema.

• Varicose veins (ask the patient to stand up). Varicose veins are often associated with incompetent valves in the long and short saphenous veins.

Do not make the common mistake of asking the patient to stand up before having

examined for varicose veins.

Palpation and special tests

• Ask about any pain in the legs and feet.

• Assess skin temperature by running the back of your hand along the leg and the sole of the

foot. Compare both legs.

• Capillary refill. Compress a nail bed for 5 seconds and let go. It should take less than 2 seconds

for the nail bed to return to its normal colour.

• Peripheral pulses (compare both sides).

– femoral pulse at the inguinal ligament

– popliteal pulse in the popliteal space (flex the knee)

– posterior tibial pulse behind the medial malleolus

– dorsalis pedis pulse over the dorsum of the foot, just lateral to the extensor tendon of the

great toe

• Buerger’s test:

– lift both of the patient’s legs to a 15 degree angle and note any collapse of the veins (‘venous

guttering’), which is indicative of arterial insufficiency

– lift both of the patient’s legs up to the point where they turn white (this is Buerger’s angle);

if there is no arterial insufficiency, the legs will not turn white, not even at a 90 degree angle

Clinical Skills for OSCEs

34 Station 14 Peripheral vascular system examination

– ask the patient to dangle his legs over the edge of the couch; in chronic limb ischaemia,

rather than returning to its normal colour, the skin will slowly turn red like a cooked lobster

(reactive hyperaemia)

• Oedema. Firm ‘non-pitting’ oedema is a sign of chronic venous insufficiency (compare to the

‘pitting’ oedema of cardiac failure).

• Varicose veins. Tenderness on palpation suggests thrombophlebitis.

• Trendelenburg’s test:

– elevate the leg to 90 degrees to drain the veins of blood

– occlude the sapheno-femoral junction (SFJ) with two fingers

– keep your fingers in place and ask the patient to stand up

– remove your fingers: if the superficial veins refill, this indicates incompetence at the SFJ

• Tourniquet test:

– elevate the leg to 90 degrees to drain the veins of blood

– apply a tourniquet to the upper thigh

– ask the patient to stand up: if the superficial veins below the tourniquet refill, this indicates

incompetent perforators below the tourniquet

– release the tourniquet: sudden additional filling of the veins is a sign of sapheno-femoral

incompetence

[Note] The tourniquet test can be repeated further and further down the leg, until the superficial veins below the

tourniquet no longer refill.

Auscultation

• Femoral arteries.

• Abdominal aorta.

• Renal arteries.

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• If appropriate, indicate that you might also measure the ABPI (see Station 15) and examine the

cardiovascular system and abdomen (aortic aneurysm).

Cardiovascular and respiratory medicine

Station 14 Peripheral vascular system examination 35

Table 6. Examination of the arterial or venous system only

Arterial system Venous system

Pallor

Shininess

Dystrophic nails

Loss of body hair

Arterial ulcers

Signs of gangrene

Skin temperature

Capillary refill

Peripheral pulses

Buerger’s test

Auscultation of femoral arteries and aorta

ABPI (if time permits, see Station 15)

Atrophie blanche

Pigmentation

Inflammation

Eczema

Lipodermatosclerosis

cmecde 5456

 

Cardiovascular and respiratory medicine

Station 12 Blood pressure measurement 27

Examiner’s questions

Causes of secondary hypertension:

• Endocrine causes:

– high catecholamines, e.g.

phaeochromocytoma

– high glucocorticoids, e.g. Cushing’s

syndrome

– high mineralocorticoids, e.g. Conn’s

syndrome

– high growth hormone, e.g. acromegaly

– hyper- or hypo-thyroidism

– hyperparathyroidism

• Renal disease

• Vascular causes:

– renal artery stenosis

– coarctation of the aorta

• Pregnancy:

– gestational hypertension

– pre-eclampsia (+ oedema and proteinuria)

• Drugs:

– NSAIDs, steroids, oestrogen, illicit drugs

Complications of hypertension:

• Cerebrovascular accident (haemorrhage or

ischaemic infarct).

• Retinopathy.

• Ischaemic heart disease.

• Left ventricular failure.

• Renal failure.

• Atherosclerosis.

• Aneurysm.

Investigations in hypertension:

• Confirming hypertension.

• Assessing for a possible secondary cause.

• Assessing for complications/end-organ

damage (see above) e.g. fundoscopy, ECG,

blood tests such as urea and electrolytes.

Artery

Stethoscope

Sphygmomanometer

Right arm

Cu�

Figure 5. Positioning of the cuff and head

of the stethoscope.

Clinical Skills for OSCEs

28 Station 13

Cardiovascular examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45 degrees, and ask him to remove his top(s).

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health,

nutritional status, and any other obvious signs). Is he breathless or cyanosed? Is he coughing?

Does he have the malar flush of mitral stenosis?

• Observe the patient’s surroundings, looking in particular for items such as a nitrate spray, an

oxygen mask, ECG electrodes, and IV lines and infusions.

• Inspect the chest for any scars and the precordium for any abnormal pulsation. A median

sternotomy scar could indicate coronary artery bypass grafting (CABG), valve repair or replacement, or the repair of a congenital defect. A left submammary scar most likely indicates repair

or replacement of the mitral valve. Do not miss a pacemaker if it is there!

Inspection and examination of the hands

• Take both hands noting:

– temperature: feel with the back of your hand

– colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains

– nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds

– any presence of clubbing (endocarditis, cyanotic congenital heart disease)

– any presence of Osler nodes and Janeway lesions (subacute infective endocarditis)

– any presence of splinter haemorrhages (subacute infective endocarditis)

– any presence of koilonychia or ‘spoon nails’ (iron deficiency)

• Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular

rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests

atrial fibrillation or multiple ectopics.

• Raise the patient’s arm above his head to assess for a collapsing/water hammer pulse (aortic

regurgitation). Ask the patient whether he has any shoulder pain first.

• Simultaneously take the pulse in both armsto exclude radio-radial delay (aortic arch aneurysm).

Indicate that you would also exclude radio-femoral delay (coarctation of the aorta).

• As you move up the arm, look for bruising, which may indicate that the patient is on an anticoagulant, and for evidence of intravenous drug use, which is a risk factor for acute infective

endocarditis.

• Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure

is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 29

Inspection and examination of the head and neck

• Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate

hyperlipidaemia.

• Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivusfor pallor, which

is indicative of anaemia.

• Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor

dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan’ssyndrome).

• Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive

of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries

simultaneously.

• Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form:

ask the patient to turn his head slightly to one side, and look at the internal vein medial to the

clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees,

the vertical height of the jugular distension from the angle of Louis (sternal angle) should be

no greater than 4 cm: if it is greater than 4cm, this suggests right heart failure, fluid overload,

or tricuspid valve disease.

Palpation of the heart

Ask the patient if he has any chest pain.

• Determine the location and character of the apex beat. It is normally located in the fifth intercostal space at the midclavicular line. The apex may be:

– impalpable: obesity, dextrocardia, situs inversus…

– displaced, suggesting volume overload (mitral or aortic regurgitation)

– heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)

– ‘tapping’, suggesting mitral stenosis

• Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.

Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted

murmurs.

45°

Height of jugular

venous distention

Angle of Louis

(sternal angle)

4 cm

Figure 6. Assessing

the jugular venous

pressure.

Clinical Skills for OSCEs

30 Station 13 Cardiovascular examination

Auscultation of the heart

• Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stethoscope’s diaphragm, listen in the:

– aortic area

right second intercostal space near the sternum

– pulmonary area

left second intercostal space near the sternum

– tricuspid area

left third, fourth, and fifth intercostal spaces near the sternum

– mitral area (use the stethoscope’s bell)

left fifth intercostal space in the mid-clavicular line

• Manoeuvres and points to remember:

– ask the patient to bend forward and to hold his breath at end-expiration. Using the stethoscope’s diaphragm, listen at the left sternal edge in the fourth intercostal space for the middiastolic murmur of aortic regurgitation

– ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the

stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis

– listen over the carotid arteries for any bruits and the radiation of the murmur of aortic

stenosis

– listen in the left axilla for the radiation of the murmur of mitral regurgitation

For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ or

throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by

palpating the carotid or brachial artery to determine the start of systole. Grade the murmur on a scale

of I to VI according to itsintensity (see Table 4). Common conditions associated with murmurs are listed

in Table 5.

A P

T

M

Mid-clavicular

line

Auscultation points

C C

Ax

Figure 7. Auscultation points.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 31

Table 4. Grading murmurs

I Barely audible murmur

II Soft and localised murmur

III Murmur of moderate intensity that is immediately audible

IV Murmur of loud intensity with a palpable thrill

V As above, murmur audible with only stethoscope rim on chest wall

VI As above, murmur audible even as stethoscope is lifted from chest wall

Table 5. Common conditions associated with murmurs

Aortic stenosis Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best

heard in the aortic area and radiating to the carotids and cardiac apex

Mitral regurgitation Displaced thrusting cardiac apex, pan-systolic murmur best heard in the

mitral area and radiating to the axilla, patient may be in atrial fibrillation

Aortic regurgitation Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the

lower left sternal edge

Mitral valve prolapse Mid-systolic click, late-systolic murmur best heard in the mitral area

RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard

loudest on Expiration

Chest examination

• Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause

pulmonary oedema and pleural effusions.

Abdominal examination

• Palpate the abdomen to exclude ascites and/or hepatomegaly.

• Check for the presence of an aortic aneurysm.

• Ballot the kidneys and listen for any renal artery bruits.

Examination of the ankles and legs

• Inspect the legs for scars that might be indicative of vein harvesting for a CABG.

• Palpate for the ‘pitting’ oedema of cardiac failure: check for pain and then press for 5 seconds

on the patient’s legs. If oedema is present, assess how far it extends. In some cases, it may

extend all the way up to the sacrum or even the torso (‘anasarca’).

• Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in

both feet.

Clinical Skills for OSCEs

32 Station 13 Cardiovascular examination

After the examination

• Indicate that you would look at the observation chart, dipstick the urine, examine the retina

with an ophthalmoscope (for hypertensive changes and the Roth’s spots of subacute infective

endocarditis), and, if appropriate, order some key investigations, e.g. FBC, ECG, CXR, echocardiogram.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a cardiovascular examination station

• Murmurs (see Table 5).

• Heart failure.

• Median sternotomy scar, with or without scar on the lower leg (vein harvesting).

• Pacemaker.