Cardiovascular PE

15/05/2023, 13:28 Cardiovascular PE
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Cardiovascular PE
Version 1 - 27/4/23
❓ Introduction
The Cardiovascular Examination is one of the most common OSCE stations to be tested on. It may present
purely "Precordium Examination" station or a general station to rule out a particular disease eg. Congestiv
Failure.
⚡ Checklist + Explanation
BEGINNING THE EXAMINATION
https://www.notion.so/Cardiovascular-PE-46f19ffa78c74058a87648a1584ce8c3 1/20
Introduction
Introduce Yourself
💡 Good morning Sir/Miss, I am (name) a first / third-year medical
student from IMU.
Obtain Patient Details
💡 Before we continue, can I have your name, age and last four digits
of your IC number?
Explain Procedure
💡 Today, I have been instructed by my senior doctor to perform a
cardiovascular examination on you. This will involve you having to
remove your upper garment and expose your chest area. I will
then be feeling around your chest and also around your body. I will
also be using my stethoscope to listen to your heart.
Assure P&C + Chaperone
💡 Rest assured that everything we discuss today will be kept private
and confidential and there is a chaperone available should you
require one too.
Obtain Consent
💡 With that, may we proceed?
Sanitise Hands
Position Patient at 45°
💡 Hint: It usually is the last / second-last hook for the black bed in CSSC
GENERAL EXAMINATION
General Inspection
Alert, Responsive, Conscious
Well-Built, Well-Nourished
Weight Loss = Cardiac Cachexia
Attached to any medical devices?
Eg. IV Drip, AED, Cardiac Pacemakers
Any apparent pain?
💡 "Sir/Miss, are you in any pain right now?”
Any respiratory distress?

Signs of Respiratory Distress
• Tachypnea
• Wheezing
• Chest Retractions
• Central Cyanosis (ie. Bluish discoloration at mouth)
• Paradoxical Abdominal Movement
(Moves out upon Expiration, Moves in upon Inspiration)
Respiratory Failure
Hands
💡 Fingernails (F) → Dorsum (D) → Palm (P)
🔥 Osler poked me (Fingertip + Painful) / Janeway comforted me (Palm
+ Painless)
Temperature & Moisture (F)
Cold & Clammy
= Heart Failure
(Due to decreased cardiac output / peripheral perfusion)
Peripheral Cyanosis (F)
Bluish discolouration @ Finger Nails
= Heart Failure / Raynaud's Phenomenon / Shock
(Due to decreased cardiac output / peripheral vasoconstriction)
Digital Clubbing (F)

💡 Check for Schamroth's window by putting both index / middle
finger touching each other
Bulging / Enlargement @ Distal portions of fingers
= Heart Failure / CHD (eg. Tetralogy of Fallot) / Infective Endocarditis
(Due to increased capillary permeability / overgrowth of soft tissues
secondary to prolonged lack of oxygen)
Capillary Refill Time (CRT) (F)

💡 Press on both fingernails for 5 seconds.
Lift one finger first to check then followed by the other.
Delayed CRT = > 2 seconds
= Dehydration / Shock / Excessive Haemorrhage
(Due to decreased peripheral perfusion secondary to hypovolaemia)
Splinter Hemorrhage (F)
Linear longitudinal haemorrhage @ Under nail
= Infective Endocarditis
(Due to blood clots / emboli in capillaries caused by bacteria)
Tendon Xanthoma (D)

Subcutaneous Nodules @ Hands / Elbow / Achilles Tendon
= Familial Hypercholesterolemia / Hyperlipidemia
(Due to deposition of cholesterol under the skin)
Tobacco Stains (D)

Smoking - Risk Factor for CAD
Pallor @ Palmar Creases (P)

Anemia / Left Ventricular HF
(Due to decreased hemoglobin < 7 g/dl)
Osler Nodes (P)

Painful & Raised Red / Purple Spots @ Fingertips
= Infective Endocarditis
Janeway Lesions (P)
Vital Signs
💡 If the vital signs values are provided, you will need to comment on
them if they are within the normal ranges or if there is any abnormality
(eg. Tachycardia).
If no vital signs are provided, proceed to measure pulse and
respiratory rate using your nurse watch, unless the examiner asks you
to omit / move on in which case vital sign measurement is not part of
the scoring sheet.
Pulse Rate
60 - 100 bpm
(Bradycardia < 60 bpm / Tachycardia > 100 bpm)
Respiratory Rate
12 - 20 breaths / min
(Bradypnea < 12 bpm / Tachypnea > 20 bpm)
Blood Pressure
90/60 mmHg ⟶ 120 / 80 mmHg
Temperature
36.2 - 37.4 °C
Eyes
💡 Remember to ask patient to remove their glasses before examining
their eyes.
Comment on any abnormalities you see even if it's not one of the
three findings below (eg. there is hemorrhage noted in the right eye).
This will indicate to the examiner that you are actually paying attention
to the findings and not regurgitating the whole sequence.
Xanthelasma
Yellowish Cholesterol Plaques @ Eyelids
= Familial Hypercholesterolemia / Hyperlipidemia
(Due to deposition of cholesterol under the skin)
Corneal Arcus
Grey Arc / Ring surrounding Iris
= Normal Aging / Familial Hypercholesterolemia / Hyperlipidemia
(Due to deposition of cholesterol / lipids)
Conjunctival Pallor
💡 Gently pull patient's eyelids downwards while asking patient to
look upwards. Check both sides simultaneously.
Pallor @ Conjunctiva = Anemia
Face
Mitral Facies
Pinkish-purplish patches @ Cheeks
= Chronic Mitral Stenosis
(Due to vasodilation in malar area while vasoconstriction in other areas)
Mouth
Central Cyanosis
Bluish Discolouration @ Lips / Mouth
= Congenital Heart Disease / Heart Failure
Dental Caries / Mucosal Petechiae

Risk Factor for Infective Endocarditis
High Arched Palate

Indicates Marfan Syndrome = High Risk for Aortic / Mitral Regurgitation
Neck
Inspection
• Any scars?
• Any redness?
• Any swelling?
• Any visible pulsations?
• Any distended neck veins?
Carotid Pulse
💡 Palpate the carotid pulse one side at a time and NEVER both
sides simultaneously.
🗣 Rate and rhythm is regular, pulse volume is normal on both sides.
Jugular Venous Pressure (JVP)

💡 Firstly, ask patient to turn their head slightly to their left. Observe
for the Internal Jugular Vein. If appreciated, proceed with JVP
measurement. ✅ If not appreciated, report as “Patient’s jugular
venous pressure is not appreciated.” ❌
💡 JVP is located between sternal head and clavicular head of Right

Sternoclavicular Muscle (SCM)
💡 Measure JVP by placing one ruler at the sternal angle

perpendicular to the floor ✅ (NOT perpendicular to sternal angle
aka slanted ❌ ) and the other ruler to measure the highest point
of JVP.
🗣 Patient’s jugular venous pressure as measured from the sternal

angle is …. cm H2O (water).
🤔 JVP vs Carotid Pulsation

JVP = Double Wave Form
Carotid Pulse = Single Pulsatile Form
🤔 The aim of measuring the JVP is to help us estimate the Right

Atrial Pressure (RAP). This is because the Right Internal Jugular
Vein is the most superficial yet direct vein leading to the right
atrium which can be easily measured externally. Using the JVP, we
can approximate the RAP by adding 5 cm H2O (ie. RAP = JVP + 5
cm H2O). This is because when the patient is lying at 45°, the JVP
is located about 5 cm from the right atrium, hence the equation
above.
Elevated JVP > 3 cm H2O = Fluid Overload 2° to Right Heart Failure
Jugular Venous Pulsations in Constrictive Pericarditis
Legs
Pitting Edema
💡 Press over the Bony Portion of Tibia / Dorsum of Foot
Presence of Bilateral Pitting Pedal Edema = Fluid Overload 2° to
Congestive Heart Failure
Pitting Edema - Example
PRECORDIUM EXAMINATION
Inspection
Chest Wall Symmetry
💡 Inspect from standing at the end of the patient’s feet
Chest Wall Deformities
Eg. Pectus Carinatum / Pectus Excavatum
Surgical Scars @ Anterior & Lateral Chest Wall

💡 Remember to ask patient to lift up their arms to allow you to
inspect the sides
Eg. Midline Sternotomy = Coronary Artery Bypass Graft (CABG)
Visible Pulsations
Eg. Lateral to Mid-Clavicular Line = Cardiac Enlargement
Eg. Shaking of Entire Precordium = Severe Aortic / Mitral Regurgitation
Visible Chest Pulsations After Cardiac Arrest
Distended Veins
Eg. Superior Vena Cava Syndrome
Palpation
Apex Beat
💡 If you are able to palpate the apex beat, you will need to then
anatomically locate it to check if it’s at the Left 5th Intercostal
Space along the Mid-Clavicular Line. ✅
💡 If you are unable to palpate the apex beat, ask the patient to turn
to their left side and feel for it again. If you still cannot feel it, just
report “Apex beat is not appreciated in this patient.” ❌
Eg. Displaced Apex Beat = Cardiomegaly @ Congestive Heart Failure
Parasternal Heave
💡 Place the heel of your hand over the lower left parasternal
border. Ask the patient to breath in, out and hold.
Eg. Presence of Parasternal Heave = Right Ventricular Hypertrophy
Thrills
Auscultation
⚠️ Always remember to palpate the carotid pulse while auscultating
heart sounds!
🤔 Reason for palpating the carotid pulse is know the timing of your heart
sounds S1 and S2. Carotid pulse can be felt during Systole (Between
S1 & S2). Hence, if a murmur coincides with the carotid pulse it is a
systolic murmur. Likewise, if it does not coincide with the carotid
pulse, it is a diastolic murmur.

Cardiovascular PE

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15/05/2023, 13:28 Cardiovascular PE

Any respiratory distress?

Digital Clubbing (F)

Capillary Refill Time (CRT) (F)

Tendon Xanthoma (D)

Tobacco Stains (D)

Pallor @ Palmar Creases (P)

Osler Nodes (P)

Janeway Lesions (P)

Dental Caries / Mucosal Petechiae

High Arched Palate

🗣 Rate and rhythm is regular, pulse volume is normal on both sides.

Jugular Venous Pressure (JVP)

💡 JVP is located between sternal head and clavicular head of Right

💡 Measure JVP by placing one ruler at the sternal angle

🗣 Patient’s jugular venous pressure as measured from the sternal

🤔 JVP vs Carotid Pulsation

🤔 The aim of measuring the JVP is to help us estimate the Right

Jugular Venous Pulsations in Constrictive Pericarditis

Surgical Scars @ Anterior & Lateral Chest Wall

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