🔍 The cardiac exam is an active, hypothesis-driven process - look, think, correlate, and integrate findings systematically. Goal: Identify structural/functional abnormalities, assess severity, and formulate a differential diagnosis. Always verbalise steps, explain to the patient, and finish by stating how you’d complete the exam (BP both arms, fundoscopy, urine dip, ECG, echo, CXR).

🫀 Overall Structured Plan (High-Yield Sequence)

🧼 Wash hands, 👋 introduce yourself, ✅ confirm ID (name/DOB), 📝 explain exam, obtain consent, offer chaperone.
🛏️ Position: 45° semi-recumbent (adjust pillow for comfort), expose chest to waist (preserve dignity with towel/blanket).
👀 General inspection (end-of-bed): patient appearance, distress, cyanosis, pallor, cachexia, respiratory effort.
Environment clues: O₂, GTN spray, IV fluids, ECG leads, drains, mobility aids, fluid charts, sputum pot.
✋ Hands & upper limbs → pulses → face & neck → chest inspection → palpation → auscultation → manoeuvres → peripheral signs → closure.

1️⃣ General Inspection (End of Bed) 👀

Patient: dyspnoea at rest, orthopnoea (extra pillows), cyanosis (central/peripheral), pallor, cachexia, jaundice (congestive hepatopathy).
Environment: oxygen (litres/min), nebulisers, GTN spray, ECG monitor, fluid balance chart, walking aids, drains (post-sternotomy).
Bedside clues: urine pot (haematuria – IE), sputum (frothy pink – pulmonary oedema), temperature chart (fever – IE).

2️⃣ Hands & Arms ✋

Inspection: clubbing (cyanotic CHD, IE), splinter haemorrhages (IE), Osler nodes (painful, IE), Janeway lesions (painless, IE), tendon xanthomata (familial hypercholesterolaemia), nicotine staining, arachnodactyly (Marfan), joint hypermobility (Ehlers-Danlos).
Temperature/perfusion: warm/cold peripheries (high/low output HF), capillary refill (<2 s normal).
Pulses:
- Rate: brady (<60), tachy (>100); count 15 s or full minute if irregular.
- Rhythm: regular / irregularly irregular (AF) / regularly irregular (ectopics, Mobitz II).
- Character: collapsing/water-hammer (AR, PDA, hyperdynamic states), slow-rising/parvus et tardus (AS), bisferiens (mixed AS/AR, HOCM), jerky (HOCM), pulsus alternans (severe LV failure), bigeminus (digoxin toxicity, ectopy).
- Comparisons: radio-radial delay (subclavian stenosis), radio-femoral delay (coarctation), pulse deficit (AF, frequent ectopy).

3️⃣ Face, Eyes, Mouth & Neck 🙂👁️🧣

Eyes: xanthelasma (hyperlipidaemia), corneal arcus (familial hypercholesterolaemia), conjunctival pallor (anaemia), Roth spots (IE), hypertensive retinopathy (Keith-Wagener-Barker grades).
Mouth: central cyanosis (lips/tongue), poor dentition (IE risk), high-arched palate (Marfan).
Face: malar flush (mitral stenosis), Down/Turner/Marfan facies (syndromic associations).
Neck:
- JVP at 45° (tangential light), measure vertical height above sternal angle + 5 cm (normal <3–4 cm).
- Waveform: giant a (pulmonary HTN, TS), cannon a (complete heart block), large v (TR).
- Hepatojugular reflux (sustained rise ≥3 cm → RV dysfunction).
- Carotid pulse: palpate one side, then auscultate for bruits (carotid stenosis, AS radiation).

4️⃣ Chest Inspection 👕

Scars: median sternotomy (CABG, valve surgery), lateral thoracotomy (PDA, coarctation), infraclavicular (PPM/ICD), axillary (minimally invasive valve).
Deformities: pectus excavatum/carinatum, scoliosis/kyphosis (Marfan, severe RVH).
Visible pulsations: RV heave, suprasternal thrill (AS), apical impulse.
Pacemaker/ICD bulge, port-a-cath scars (long-term antibiotics – IE).

5️⃣ Palpation 🤲

Apex beat: normal 5th ICS, mid-clavicular line; displaced laterally/downward (LV dilatation), heaving (LVH), tapping (MS).
Heaves: left parasternal (RVH, pulmonary HTN), apical (LVH).
Thrills: palpable murmurs (e.g., grade 4+ AS at aortic area, MR at apex).

6️⃣ Auscultation 🎧 – Systematic & Targeted

Areas (use diaphragm for high-pitched, bell for low-pitched; patient breathing normally then held expiration):
- 🔴 Aortic area – 2nd ICS right sternal border
- 🔵 Pulmonary area – 2nd ICS left sternal border
- 🟢 Tricuspid area – lower left sternal edge (4th–5th ICS)
- 🟣 Mitral area – apex (5th ICS mid-clavicular line)
- Axilla → radiation of MR
- Carotids → radiation of AS (after checking bruits)
Heart sounds: S1 (mitral/tricuspid closure), S2 (aortic/pulmonary closure; physiological splitting on inspiration), loud/soft, fixed/reversed splitting.
Extra sounds: S3 (ventricular gallop – HF), S4 (atrial kick – stiff LV), opening snap (MS), ejection click (bicuspid aortic valve), mid-systolic click (MVP).
Murmurs: timing (systolic/diastolic/continuous), grade (1–6), character (harsh/blowing), radiation, response to manoeuvres.
Pericardial rub: scratchy, triphasic, best leaning forward.

Common heart murmur locations, timing, and radiation patterns – high-yield OSCE reference

7️⃣ Special Manoeuvres (Increase Diagnostic Yield) ⚡

Valsalva (strain phase) → ↑ HOCM murmur, ↓ AS/MR.
Handgrip (isometric) → ↑ MR/AR/VSD, ↓ AS/HOCM.
Left lateral decubitus + bell → accentuates MS rumble, S3/S4.
Sit forward + breath held in expiration → accentuates AR (high-pitched decrescendo).
Standing/squatting → dynamic changes in HOCM (↑ on standing, ↓ on squatting).

8️⃣ Peripheral Signs & Systemic Clues 👣🫁

Lung bases: bilateral crackles (pulmonary oedema in HF).
Sacral/ankle oedema: pitting (RHF, constrictive pericarditis, nephrotic syndrome).
Legs: saphenous vein harvest scars (CABG), varicose veins, DVT signs.
Abdomen: hepatomegaly (RHF), ascites (shifting dullness), pulsatile liver (TR).
Other: sacral oedema, pleural effusion (HF), splenomegaly (IE).

9️⃣ Closure & Completion 🙏

Thank patient, cover up, help redress.
Wash hands.
Present findings clearly & succinctly (e.g., “This patient has an ejection systolic murmur loudest in the aortic area, radiating to carotids, slow-rising pulse, narrow pulse pressure – consistent with severe aortic stenosis”).
State: “To complete my examination, I would like to measure BP in both arms, perform fundoscopy, dip urine for protein/haematuria, and arrange ECG and transthoracic echo.”

OSCE Examiner Tips & High-Yield Phrases • Verbalise everything: “I’m now palpating for the apex beat in the 5th intercostal space, mid-clavicular line...” • If you miss something: “I would also check for...” – still scores points. • JVP: “I’m assessing JVP at 45° with tangential light; hepatojugular reflux is negative.” • Murmurs: describe timing, site, grade, radiation, character, manoeuvres. • Always integrate: “The collapsing pulse and wide pulse pressure support aortic regurgitation.” • Do-not-miss: new murmur + fever + embolic signs = infective endocarditis → urgent echo + blood cultures.

📊 High-Yield Cardiac Examination Findings Table

Finding	Key Features	Associated Conditions	Technique / Clue
Collapsing pulse	Bounding upstroke, rapid collapse	Aortic regurgitation, PDA, AV fistula, thyrotoxicosis	Raise arm above head
Slow-rising pulse	Parvus et tardus	Severe aortic stenosis	Carotid palpation
Displaced apex beat	Lateral/downward	LV dilatation (MR, AR, DCM)	5th ICS, anterior axillary line
Heaving apex	Sustained thrust	LV hypertrophy (AS, HTN)	Palpation
Parasternal heave	RV lift	Pulmonary hypertension, RVH	Left sternal edge
S3	Early diastolic gallop	Heart failure, volume overload	Bell at apex, left lateral
S4	Late diastolic	Stiff LV (HTN, AS)	Bell at apex
Opening snap	Sharp sound after S2	Mitral stenosis	Left lateral, bell
Pericardial rub	Scratchy, triphasic	Acute pericarditis	Lean forward, breath hold

🚩 Do-Not-Miss Red Flags in OSCE

Fever + new murmur + embolic signs → infective endocarditis
Syncope + ejection systolic murmur in elderly → severe AS
Diastolic murmur → always pathological (AR/MS)
Discrepant arm BP + radio-femoral delay → coarctation/aortic dissection
Raised JVP + Kussmaul sign → constrictive pericarditis

📚 References & Resources (Feb 2026)

Talley & O’Connor – Clinical Examination (9th ed., 2025 update).
Geeky Medics Cardiovascular Examination OSCE Guide (2026 revision).
OSCEstop & PassMedicine cardiology sections.
ESC Guidelines: Valvular Heart Disease (2025 update).

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Cardiology Examination (OSCE)