CVS examination

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Before You Start

Standard Setup

CVS Examination Checklist

Introduce yourself, explain exam, obtain consent
Ensure privacy, warmth, good lighting. Wash hands.
Stand on the right side of the patient
Position patient semi-recumbent at 45°
Expose anterior chest to the umbilicus (above waist)
General observation: conscious, alert, oriented — looks well or ill — breathless, cyanosed, distressed
Record vitals: RR, Temp, BMI, BP, Pulses

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History Taking

Chief Complaints

A — Chest Pain

	Angina	MI	Aortic Dissection	Acute Pericarditis
Site	Retrosternal	Retrosternal	Retrosternal, Intrascapular	Retrosternal or left-sided
Onset	Gradual 1–2 min	Rapid few mins	Very sudden	Gradual; postural change aggravates
Character	Constricting, heavy	Constricting, heavy	Tearing, ripping	Sharp, stabbing, pleuritic
Radiation	Arms, neck, epigastrium	Arms, neck, jaw	Back, between shoulders	Lt shoulder or back
Relieving	Rest, nitrates	NOT relieved by rest	Nothing relieves	Sitting up, leaning forward, NSAIDs
Associated	Breathlessness	Sweating, nausea, Angor Animi	Syncope, focal neuro signs	Flu-like prodrome, fever

B — Shortness of Breath (Dyspnea)

Breathlessness: Onset → Diagnosis

Minutes: PE, Pneumothorax
Hours–days: Pneumonia, Asthma
Weeks–months: Anaemia, Pleural effusion
Months–years: COPD, Pulmonary fibrosis

MRC Breathlessness Scale

Grade 1: Hurrying on level/hill
Grade 2: Walking with peers on level
Grade 3: Walks slower than peers
Grade 4: Stops after 100m
Grade 5: Too breathless to leave house
Grade 5b: Too breathless to wash/dress

C — Palpitations

	Extrasystoles	Sinus Tachy	SVT	AF	VT
Onset	Sudden	Gradual	Sudden, with 'jump'	Sudden	Sudden
Character	'Jump', missed beat	Regular, fast, pounding	Regular, fast	Irregular, fast	Regular, fast
Associated	Nil	Anxiety	Polyuria, chest tightness	Breathlessness	Presyncope, syncope
Severity	Mild	Mild–moderate	Moderate–severe	Variable	Often severe

D — Syncope

	Postural Hypotension	Vasovagal	Arrhythmias	Mechanical
Onset	On standing	Sudden	Sudden	—
Prodrome	Lightheadedness, tinnitus, dark vision, sweating	Same as left	Palpitations, chest pain, SOB	—
Duration	1–2 mins	<60 seconds	—	—
DDx	Hypovolemia, drugs (diuretics)	Vasovagal attack	VT, complete heart block	Severe AS, HOCM, PE

E — Lower Limb Swelling

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Hands

Peripheral Signs

Hands examination — nails, palms, dorsum

Inspection — What to Look For

Nails: Tobacco stain · peripheral cyanosis · clubbing · splinter haemorrhages
Palms: Janeway spots · Osler nodes · pallor · palmar erythema
Dorsum: Petechial rash · tendon xanthomata

IV drug use sites
Tremor (fine + flapping)
Temperature + sweaty or dry

Palpation

Temperature (wet / dry)
Capillary refill — normally <2 seconds
Pulses (see next section)

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Face

Facial Signs

Face examination — xanthelasmata, malar flush, central cyanosis, corneal arcus

Eyes

Xanthelasmata on eyelids
Conjunctival pallor and petechial haemorrhage
Corneal arcus on iris
Fundoscopy — DM/HTN changes, Roth spots

Cheeks & Mouth

Malar flush — suggests mitral stenosis
Central cyanosis under the tongue
Peripheral cyanosis on the lips
Dental caries (infective endocarditis risk)

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Pulse Examination

Rate · Rhythm · Volume · Character

Radial pulse — feel just lateral to flexor carpi radialis tendon with pads of 3 fingers

Comment on: Rate · Rhythm · Volume · Character · Compressibility — Then radio-radial delay · radio-femoral delay · collapsing pulse · pulse deficit

Pulse Locations

$Pulse deficit technique$ Brachial artery technique

⚠️ Carotid Pulse — Critical Safety Rule

NEVER feel both sides simultaneously — risk of cerebral ischaemia.
Auscultate for bruit on BOTH sides while patient holds breath.

Pulse	Location	Comment On
Radial	Just lateral to flexor carpi radialis tendon	Rate, rhythm, volume, character, radio-radial delay, collapsing pulse, deficit
Brachial	Medial to biceps tendon in antecubital fossa	Volume, character, compressibility
Carotid	Between larynx and anterior border of SCM	ONE SIDE ONLY — auscultate for bruit
Femoral	Midpoint of inguinal ligament (ASIS → pubic symphysis)	Bruits
Popliteal	Press firmly behind 30° flexed knee, both hands	Palpable / not palpable
Post. Tibial	2cm below and behind medial malleolus	Palpable / not palpable
Dorsalis Pedis	Lateral to extensor hallucis longus, against navicular	Absent in 2–3% of healthy individuals

Pulse Rate & Rhythm

Pulse Character

Slow Rising

Gradual upstroke with reduced peak occurring late in systole

Severe aortic stenosis

Collapsing (Water Hammer)

Peak arrives early → rapid fall; wide pulse pressure (systolic – diastolic >80 mmHg)

Severe aortic regurgitation, PDA

Pulsus Bisferiens

Double systolic peak separated by a mid-systolic dip

AS + AR combined, HOCM

Pulsus Alternans

Beat-to-beat variation in volume with normal rhythm

Advanced heart failure

Pulsus Paradoxus

Exaggerated normal variation with breathing (>10 mmHg fall in systolic on inspiration)

Cardiac tamponade, pericardial constriction, acute severe asthma

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Blood Pressure

Korotkoff · Classification

BP Measurement Technique

1
Rest 5 minutes, no tight clothing
2
Support arm at heart level
3
Apply proper-sized cuff — bladder over brachial artery
4
Palpate brachial artery → inflate to 30 mmHg above impalpable pulse
5
Deflate slowly — Phase 1 = systolic, Phase 5 = diastolic
6
Measure both arms; record site and position

BP Category	Systolic (mmHg)	Diastolic (mmHg)
Optimal	<120	<80
Normal	<130	<85
High Normal	130–139	85–89
HTN Grade 1 (mild)	140–159	90–99
HTN Grade 2 (moderate)	160–179	100–109
HTN Grade 3 (severe)	>180	>110

📈

Jugular Venous Pressure (JVP)

Right Atrial Pressure

British Hypertension Society classification

Approach to hypertension / secondary HTN

Clinical clues to secondary hypertension

JVP Examination Sequence

1
Position patient supine at 45°, pillow behind head, head slightly turned left
2
Inspect: use tangential light → look for rapid inward movement, two waves per pulse
3
Palpate: JVP is impalpable — compresses with neck pressure and disappears
4
Special manoeuvres: respiration (↓ inspiration), lie flat (↑), sit up (↓), abdominojugular reflux
5
Measure height: vertical distance from tip of visible pulsation to sternal angle. Normal <9 cmH₂O

JVP Waveforms

a

Atrial systole

Right atrial contraction. Absent in AF. Giant in tricuspid stenosis.

c

Tricuspid closure

RV contraction pushing tricuspid valve back into RA

x

x descent

Downward displacement of tricuspid ring during systole

v

Venous filling

Peak RA pressure before tricuspid opens. Giant in TR.

y

y descent

Commencement of ventricular filling. Prominent in pericardial constriction.

Condition	JVP Finding
Heart failure	Elevation + sustained abdominojugular reflux >10 seconds
Pulmonary embolism / Tamponade	Elevation
Pericardial effusion	Elevation + flattened 'y' descent
Pericardial constriction	Elevation + Kussmaul's sign + prominent 'y' descent
SVC obstruction	Elevation + loss of pulsation (non-pulsatile)
Atrial fibrillation	Absent 'a' waves
Tricuspid stenosis	Giant 'a' waves (large, prominent)
Tricuspid regurgitation	Giant 'v' or 'cv' waves
Complete heart block	'Cannon' waves

Kussmaul's Sign

Paradoxical rise of JVP with inspiration

DDx: Pericardial constriction · Severe RV failure · Restrictive cardiomyopathy

❤️

Precordial Examination

Inspect · Palpate

Precordium examination — Inspection · Palpation · Auscultation

Inspection

What to Inspect

1
From foot of bed: chest deformities (pectus excavatum, barrel chest) and body hair distribution
2
From right side (lean forward to see left axilla): scars, masses, visible pulsations, dilated veins
3
Visible pulsations — apex beat, parasternal pulsations
4
Surgical scars — sternotomy, pacemaker insertion, chest drain sites

Palpation — Apex Beat

Apex Beat — Technique

1
Find most lateral and inferior palpable pulse using entire palm
2
Confirm location with 2 fingers — should be left 5th ICS, mid-clavicular line
3
If impalpable → tilt patient to left lateral decubitus position
4
If still impalpable → consider hyperinflated lungs (COPD) or dextrocardia

Impalpable

Hyperinflated lungs (COPD) or dextrocardia

Diffuse + displaced inferolaterally

LV dilatation

Forceful + undisplaced

LV hypertrophy

Double impulse

Hypertrophic cardiomyopathy

Tapping

Mitral stenosis (palpable S1)

Heave

Use the heel of your hand at the left parasternal area at end of expiration.
A heave suggests RV hypertrophy or dilatation / pulmonary HTN.

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Auscultation

Heart Sounds · Murmurs

Auscultation Sequence

1
Diaphragm — all 4 areas (Aortic, Pulmonary, Tricuspid, Mitral). Keep other hand on carotid. Ask to breathe deep at pulmonic for splitting. Auscultate left axilla (MR) and carotids while breath-held (AS).
2
Sit and lean forward, hold breath → auscultate aortic area + Erb's point for early diastolic murmur of AR
3
Bell over all 4 areas — S3, S4. Roll patient to left lateral position + bell for mid-diastolic murmur of MS

Left lateral position and lean forward positions

Heart Sounds

Normal Sounds

S1 (Lub): Closure of mitral + tricuspid valves. Loudest at apex.
S2 (Dub): Closure of aortic + pulmonary valves. Loudest at base.
Physiological splitting of S2 on inspiration (normal)
Fixed splitting → ASD
Paradoxical splitting → AS / LBBB

Added Sounds

S3: Normal in young; gallop in adults = heart failure
S4: Always pathological → stiff ventricle (LVH)
Opening Snap: After S2 → mitral stenosis
Ejection Click: After S1 → valve stenosis
Friction Rub: Pericarditis

Murmurs

Aortic Stenosis (AS)

Midsystolic ejection murmur

Best heard: 2nd right ICS (aortic area)
Radiates to: carotids
Harsh, crescendo-decrescendo

Mitral Regurgitation (MR)

Pansystolic murmur

Best heard: Apex
Radiates to: left axilla
Blowing, uniform intensity

Aortic Regurgitation (AR)

Early diastolic murmur

Best heard: Erb's point (3rd–4th left ICS)
Patient: sitting + leaning forward + breath-held at end expiration
Soft, blowing, decrescendo

Mitral Stenosis (MS)

Mid-diastolic murmur

Best heard: Apex with BELL
Patient: left lateral position
Only murmur heard with the BELL

"Normal S1 and S2 with physiological splitting of S2 on inspiration. No added sounds (S3, S4, opening snap, ejection click, friction rub). No murmurs." — Normal Auscultation OSCE Comment · If murmur: location, radiation, timing, character, pitch

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Lower Limb & Peripheral Vascular

PVD · Ulcers · Neurological

Inspection

Signs of Ischemia

Amputated limb/toe · Thick hypertrophied nails
Peripheral cyanosis · Pallor · Hair loss
Dry/shiny skin · Decreased muscle bulk
Black discoloration of toes (gangrene)
Charcot's joint deformity
Check heel and between toes for ulcers

Signs of Venous Insufficiency

Visible distended / tortuous veins
Redness or hyperpigmentation (haemosiderin)
Thick skin · Obvious scars · Ulcers
Obvious swelling

Ulcer Types & Sites

Arterial ulcer
Tip of toes, dorsum of foot — pale, deep, painful, punched-out

Venous ulcer (long saphenous)
Medial side of leg (gaiter area)

Venous ulcer (short saphenous)
Lateral side of leg

Pressure ulcer
Over sole at pressure points

Palpation

Special Tests

Buerger's Test (PAD)

1
Raise legs to 45°, support for 2–3 minutes
2
Watch for pallor + 'guttering' of superficial veins
3
Sit patient up, hang legs over bed edge
4
Cyanosis before returning pink → positive = PVD

Trendelenburg Test (Varicose Veins)

1
Elevate leg — 'milk' veins toward groin
2
Press sapheno-femoral junction (2–3 cm below + lateral to pubic tubercle)
3
Ask patient to stand while maintaining pressure
4
Veins fill on releasing → sapheno-femoral incompetence

Ankle-Brachial Index (ABI)

ABI Interpretation

>1.4

Calcification / vessel hardening

→ Vascular specialist

1.0–1.4

Normal

None

0.9–1.0

Acceptable

None

0.8–0.9

Some arterial disease

Treat risk factors

0.5–0.8

Moderate arterial disease

→ Vascular specialist

<0.5

Severe arterial disease

→ Vascular specialist (urgent)

Neurological Examination

Neurological examination — light touch · pin-prick · vibration · proprioception · ankle jerk

To Complete the Examination

Always state these at the end of your OSCE presentation

• Lung bases — auscultate for crackles
• Hepatomegaly and ascites
• Lower limb and sacral oedema
• Examine inguinal lymph nodes and gait

Course Access

Cardiovascular System& Peripheral Vascular Examination

Paradoxical rise of JVP with inspiration

Always state these at the end of your OSCE presentation

Cardiovascular System
& Peripheral Vascular Examination