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NAC OSCE preparation

Station 27: Complete cardiovascular examination in heart failure

Complete the task in 11 minutes. Reveal the full standardized-patient script, examiner prompts and structured debrief only after your attempt.

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Station time

11:00

Ready for an 11-minute attempt.

Candidate instructions

Complete cardiovascular examination in heart failure

11 minutes

Discipline: Physical Examination
Station type: Complete focused cardiovascular examination + oral presentation
Setting: Internal medicine ward

Your task

Perform a complete focused cardiovascular examination on this 69-year-old patient with dyspnea and ankle swelling. Assess stability first, explain each step, preserve dignity, and adapt the examination to symptoms. At the end, present your findings, leading diagnosis, prioritized differential, targeted investigations, immediate management and safety-netting. Do not perform fundoscopy, rectal, genital or breast examination. You have 11 minutes.

Information available at entry

HR 96/min regularBP 148/86 mm HgRR 22/minSpO₂ 93% room air

Coach prompt: Perform a safe, systematic cardiovascular examination; identify congestion, valvular findings and poor perfusion; then present a prioritized diagnosis, targeted investigations, immediate management and safety-netting.

In Exam Mode, coaching cues are hidden. Ask a partner to use the standardized-patient script after you start the timer.

Finished your attempt?Reveal the full station only after completing or stopping the timer.

Complete station package

Standardized-patient script and structured debrief

Station 27 of 30

Standardized-patient profile

NameMr. Adrian Lee

Age69

Pronounshe/him

RolePatient

Demeanour: Comfortable at rest, mildly breathless when lying flat.

Opening statement: “I get short of breath and my ankles have become swollen.”

History and standardized-patient responses

Brief safety questions before positioning

Candidate explores	Standardized-patient response
Current chest pain	No current chest pain.
Breathing at rest	Mildly short of breath; breathing becomes worse when lying flat.
Pain with movement or examination	No pain with movement. The patient prefers to remain at 45 degrees.

Information if requested after the examination

Candidate explores	Standardized-patient response
Heart-failure symptoms	Progressive exertional dyspnea, orthopnea requiring three pillows, two episodes of paroxysmal nocturnal dyspnea, and bilateral ankle swelling.
Possible precipitant	Missed several diuretic doses during the past week and has eaten more salty prepared food. No fever or productive cough.
Cardiac background	Previous anterior myocardial infarction, hypertension and known reduced left-ventricular ejection fraction.
Medication/allergy	Furosemide, sacubitril/valsartan, carvedilol, spironolactone and dapagliflozin. No known drug allergies.

Complete 11-minute examination procedure

Use the sequence as a structured guide. In a real station, adapt immediately to the task and the patient’s stability.

0:00–0:30

Safety glance before touching the patient

Suggested wording: “Before I begin, I am checking that you are stable enough for the examination. Are you having chest pain, severe shortness of breath, dizziness or feeling faint right now?”

Observe from the doorway/end of bed for respiratory distress, altered mentation, cyanosis, diaphoresis and ability to speak.
Review the provided heart rate, blood pressure, respiratory rate and oxygen saturation.
If unstable, call for help, begin ABC management and do not continue a routine examination.

0:30–1:05

Introduction, identity, explanation and consent

Suggested wording: “Hello, my name is ____, one of the clinical candidates. Could I confirm your full name and date of birth? I have been asked to examine your heart and circulation. This will involve looking, feeling and listening over your chest, neck, abdomen and legs. Is that okay?”

Introduce name and role.
Confirm two identifiers.
Explain the focused examination in plain language and obtain consent.
Offer a chaperone when appropriate under local policy or patient preference.

1:05–1:30

Hand hygiene, pain check, positioning and exposure

Suggested wording: “I will clean my hands first. Do you have any pain before I begin? I will keep you at about 45 degrees because lying flat may worsen your breathing. I will expose only the areas I need and keep you covered as much as possible.”

Perform hand hygiene.
Ask about pain and whether any movement worsens breathing.
Position at 30–45 degrees; do not force an orthopneic patient supine.
Expose the chest appropriately while maintaining dignity and warmth.

1:30–2:05

General inspection from the end of the bed

Suggested wording: “I am first looking for signs of breathing difficulty, circulation problems or fluid retention.”

Assess respiratory effort, colour, body habitus, distress and mental status.
Look for oxygen, monitors, IV lines, medication devices and mobility aids.
Note chest scars, pacemaker/ICD contour, visible edema and overall perfusion.

2:05–2:50

Hands, peripheral perfusion and pulse

Suggested wording: “May I examine your hands and feel your pulse?”

Assess hand temperature, capillary refill, peripheral cyanosis and clubbing.
Look only for relevant stigmata such as splinter hemorrhages, Janeway lesions or Osler nodes when infection is a concern.
Palpate the radial pulse for rate, rhythm, volume and character.
Compare both radial pulses when asymmetry or aortic disease is relevant; state blood-pressure assessment.

2:50–3:15

Face and mouth

Suggested wording: “I am checking your eyes and lips for signs such as pallor or low oxygen.”

Inspect conjunctivae for pallor.
Inspect lips and tongue for central cyanosis.
Note xanthelasma or corneal arcus only when clinically relevant; do not let minor signs consume time.

3:15–4:20

Carotid pulse and jugular venous pressure

Suggested wording: “I am going to examine the pulses and veins in your neck. I will press gently on one side at a time.”

Palpate one carotid artery at a time for character and volume when indicated; never compress both sides.
Use tangential light and adjust the patient between 30 and 45 degrees to identify the JVP.
Measure the vertical height above the sternal angle and describe waveform when visible.
Use hepatojugular reflux briefly when JVP is uncertain or right-sided filling pressure needs clarification; stop if uncomfortable.

4:20–5:20

Precordial inspection and palpation

Suggested wording: “I will now look at and gently feel the front of your chest to assess the heart’s position and movement.”

Inspect for scars, chest-wall deformity, pacemaker/ICD and visible pulsations.
Locate and characterize the apex beat by position and quality.
Assess for a parasternal heave and palpable thrills over valve areas.
Avoid excessive or repeated palpation when it adds no diagnostic value.

5:20–6:45

Cardiac auscultation and focused maneuvers

Suggested wording: “I am going to listen to your heart in several places. Please breathe normally. I may ask you to change position briefly if you are comfortable.”

Auscultate aortic, pulmonary, tricuspid and mitral areas with the diaphragm.
Use the bell at the apex for low-pitched sounds such as an S3, S4 or mitral stenosis murmur.
Assess S1, S2, added sounds, rhythm and any murmur’s timing, location, intensity, radiation and response to maneuvers.
Use the left lateral position for apical low-pitched sounds only if tolerated.
Use sitting forward in expiration for an aortic-regurgitation murmur only if clinically indicated.
Do not perform multiple ritual maneuvers when the patient is breathless or the finding is already clear.

6:45–7:35

Respiratory examination for pulmonary congestion

Suggested wording: “I also need to listen to the lungs because heart problems can cause fluid to collect there.”

Inspect respiratory pattern and chest expansion.
Auscultate both anterior fields and posterior/lateral bases, comparing sides.
Identify fine bibasal crackles, wheeze, reduced air entry or focal findings.
Consider a brief percussion assessment when pleural effusion or another pulmonary process is suspected.

7:35–8:20

Peripheral edema and lower-limb perfusion

Suggested wording: “I am checking your legs for swelling and circulation.”

Inspect and palpate for bilateral pitting edema, documenting the level.
Assess lower-limb temperature and peripheral pulses when perfusion is in question.
Check sacral edema if the patient is immobile or dependent edema is suspected.
Do not use Homan sign or forcefully squeeze the calves.

8:20–8:55

Abdominal signs of systemic congestion

Suggested wording: “With your permission, I will briefly examine your abdomen for fluid or liver enlargement.”

Palpate gently for hepatomegaly and tenderness.
Assess for ascites only when clinically indicated.
Mention additional examination such as weight, urine output and fundoscopy rather than performing excluded or time-consuming maneuvers.

8:55–9:20

Complete the patient encounter respectfully

Suggested wording: “Thank you. The examination is complete. I will help you sit comfortably and cover you again. Has your breathing or discomfort changed?”

Return the patient to the preferred upright position.
Replace clothing/gown and drape.
Perform hand hygiene after examination.
Thank the patient and reassess symptoms.

9:20–10:05

Present the findings concisely

Suggested wording: “This patient is mildly tachypneic but alert, warm and hypertensive. The pulse is regular. JVP is elevated with a positive hepatojugular response. The apex is displaced and diffuse. There is an S3 and an apical pansystolic murmur radiating to the axilla. Bibasal crackles, bilateral pitting edema and tender hepatomegaly indicate pulmonary and systemic congestion. There are no clinical signs of shock.”

Use general appearance, pulse/perfusion, JVP, precordium, auscultation, lungs and edema as the presentation order.
State important negatives that affect severity or alternatives.
Do not report findings that were not elicited or provided.

10:05–11:00

Diagnosis, prioritized investigations, management and safety net

Suggested wording: “The leading diagnosis is acute decompensated heart failure, likely ischemic cardiomyopathy with functional mitral regurgitation. I would keep him upright, repeat vital signs, start monitoring and IV access, obtain an ECG, chest radiograph, targeted blood tests and echocardiography, give oxygen only if hypoxemic, treat congestion with monitored loop-diuretic therapy, identify and treat the precipitant, and escalate immediately if he develops worsening hypoxemia, hypotension, confusion, oliguria or cool peripheries.”

State the leading diagnosis first and name the likely severity profile.
Prioritize common and dangerous precipitants rather than listing every cause.
Link each investigation to a clinical question.
Organize management into stability, congestion treatment, precipitant treatment, monitoring, disposition and follow-up.
Stop when the station signal sounds.

Physical findings

General and stability: alert, mildly tachypneic and more breathless when supine; speaking in full sentences; no central cyanosis; SpO₂ 93% on room air.
Hands and perfusion: hands warm, capillary refill under 2 seconds; no clubbing, splinter hemorrhages or peripheral cyanosis.
Pulse and blood pressure: radial pulse 96/min, regular and of normal volume; no radio-radial delay; BP 148/86 mm Hg.
Face: no conjunctival pallor or central cyanosis.
Neck: JVP elevated approximately 5 cm above the sternal angle at 45 degrees with a positive hepatojugular response; carotid upstroke not delayed.
Precordium: no scar; apex beat displaced to the sixth intercostal space at the anterior axillary line and diffuse; no parasternal heave; no palpable thrill.
Auscultation: normal S1 and S2 with an S3 gallop. Grade 3/6 pansystolic murmur maximal at the apex and radiating to the axilla, consistent with mitral regurgitation.
Respiratory: bibasal fine inspiratory crackles; no focal bronchial breathing or wheeze.
Volume status: bilateral pitting ankle edema to the lower shins; no sacral edema.
Abdomen: mild tender hepatomegaly; no clinically obvious ascites.
Overall interpretation: congested but currently warm and hypertensive, without clinical evidence of cardiogenic shock.

Examiner prompts

Present the examination findings in 30–45 seconds.

The patient is mildly tachypneic but alert, warm and hypertensive. Pulse is regular. JVP is elevated with a positive hepatojugular response. The apex is displaced and diffuse. There is an S3 and an apical pansystolic murmur radiating to the axilla. Bibasal crackles, bilateral pitting edema and mild tender hepatomegaly indicate systemic and pulmonary congestion. There are no clinical signs of shock.

What is the leading diagnosis?

Acute decompensated heart failure with biventricular congestion, likely on an ischemic cardiomyopathy background, with functional mitral regurgitation.

Give a prioritized differential or precipitant list.

Medication or dietary nonadherence, acute coronary syndrome, arrhythmia, uncontrolled hypertension, infection, renal dysfunction, medication-related fluid retention, anemia or thyroid disease. Pulmonary embolism remains a dangerous alternative when supported by history or examination.

What investigations would you request first?

Repeat vital signs and continuous monitoring; ECG; chest radiograph; CBC, electrolytes, urea/creatinine, glucose and liver tests; troponin when ischemia is possible; natriuretic peptide where diagnostically useful; urinalysis; echocardiography to assess ventricular and valvular function; additional testing guided by the suspected precipitant.

What is your immediate management?

Sit upright, obtain IV access and monitoring, give supplemental oxygen only for hypoxemia, use loop diuretic therapy for congestion with urine-output/renal/electrolyte monitoring, consider vasodilator therapy if hypertensive and appropriate, treat the precipitant, and escalate urgently for worsening respiratory failure, hypotension, altered mentation, oliguria or cool peripheries.

Differential diagnosis

Acute decompensated heart failure due to ischemic cardiomyopathy
Functional or structural mitral regurgitation contributing to congestion
Acute coronary syndrome as a precipitant
Arrhythmia-related decompensation
Hypertensive acute heart failure
Renal dysfunction or medication/dietary nonadherence causing fluid overload
Pneumonia or other infection
Pulmonary embolism or another non-cardiac cause of dyspnea

Investigations

Repeat complete vital signs, oxygen saturation, cardiac monitoring and strict fluid-balance assessment.
12-lead ECG to assess ischemia, arrhythmia, conduction disease and prior infarction.
Chest radiograph for pulmonary congestion, pleural effusions, cardiomegaly and alternative lung pathology.
CBC, electrolytes, urea/creatinine, glucose, magnesium and liver tests; urinalysis when relevant.
High-sensitivity troponin when acute coronary syndrome or myocardial injury is possible.
BNP or NT-proBNP when the diagnosis is uncertain or for supportive risk assessment, interpreted in context.
Transthoracic echocardiography for ventricular function, regional wall motion and valve disease.
Precipitant-directed tests such as cultures, thyroid testing, D-dimer/CT pulmonary angiography or medication review only when indicated.

Management

Assess airway, breathing, circulation, mentation and perfusion; call for urgent assistance if instability is present.
Sit upright, establish IV access, use continuous cardiac/oxygen monitoring and reassess frequently.
Give supplemental oxygen only when hypoxemic; consider non-invasive ventilatory support for persistent hypoxemia or severe pulmonary edema according to local protocol.
Treat pulmonary or peripheral congestion with loop diuretic therapy while monitoring urine output, weight, renal function and electrolytes.
Consider vasodilator therapy in hypertensive acute heart failure when clinically appropriate and not contraindicated.
Identify and treat the precipitant, including ischemia, arrhythmia, infection, uncontrolled blood pressure, renal dysfunction or nonadherence.
Review chronic guideline-directed heart-failure therapy after stabilization rather than reflexively changing every long-term medication during the initial examination station.
Escalate to emergency, cardiology or critical-care support for hypotension, cool peripheries, oliguria, altered mental status, refractory hypoxemia or worsening work of breathing.
Before discharge, ensure medication reconciliation, daily-weight instructions, sodium/fluid advice where appropriate, follow-up and explicit return precautions.

Communication behaviours

Explains the need to keep the patient at 45 degrees and does not force the patient flat when orthopneic.
Explains each maneuver before touching the neck, chest, abdomen or legs.
Uses limited exposure and draping, and offers a chaperone when local policy or patient preference indicates.
Checks for breathlessness, dizziness or discomfort during repositioning and dynamic maneuvers.
Uses calm, concise language and closes with the leading concern and immediate next steps.

Critical safety actions

Assess stability before beginning a ritual examination; stop and escalate if respiratory distress, hypoxemia, hypotension, altered mentation or poor perfusion develops.
Do not force an orthopneic patient to lie flat.
Do not omit JVP, lung bases, peripheral edema and perfusion when assessing suspected heart failure.
Palpate only one carotid artery at a time and do not apply prolonged pressure.
Do not delay urgent treatment for a prolonged examination in a clinically unstable patient.
Give supplemental oxygen for hypoxemia rather than automatically to every patient with heart failure.
Recognize cool peripheries, prolonged capillary refill, hypotension, confusion and oliguria as possible low-output/cardiogenic shock signs.

Model closing summary

This 69-year-old man is mildly tachypneic and congested but currently alert, warm and hypertensive, without clinical shock. His JVP is elevated with a positive hepatojugular response, the apex is displaced and diffuse, and there is an S3 with an apical pansystolic murmur radiating to the axilla. Bibasal crackles, bilateral pitting edema and mild tender hepatomegaly indicate pulmonary and systemic congestion. The leading diagnosis is acute decompensated heart failure on an ischemic cardiomyopathy background, with likely functional mitral regurgitation. I would keep him upright, repeat vital signs, begin cardiac and oxygen monitoring, obtain IV access, ECG, chest radiograph, targeted blood tests and echocardiography, give oxygen only if hypoxemic, start monitored loop-diuretic therapy for congestion, assess for ischemia, arrhythmia, infection, renal dysfunction and nonadherence, and escalate urgently if he develops worsening respiratory failure or signs of low output.

Common pitfalls

Starting with the hands while ignoring obvious respiratory distress or abnormal vital signs.
Skipping identity, consent, hand hygiene, pain assessment or patient comfort.
Laying an orthopneic patient flat or exposing more than necessary.
Estimating JVP without correct positioning, tangential lighting and a clear reference to the sternal angle.
Listening through clothing or failing to use both diaphragm and bell when appropriate.
Performing every textbook peripheral sign even when it does not answer the station task.
Forgetting lung bases, edema, perfusion or hepatomegaly in a heart-failure examination.
Calling all crackles heart failure without considering infection or another lung process.
Presenting a list of findings without an integrated severity statement or prioritized diagnosis.
Giving chronic medication details before addressing immediate stability and congestion.
Using routine oxygen in a patient who is not hypoxemic.
Failing to thank, cover and reposition the patient before presenting.

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

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Station 27: Complete cardiovascular examination in heart failure

Complete cardiovascular examination in heart failure

Standardized-patient script and structured debrief

Standardized-patient profile

History and standardized-patient responses

Brief safety questions before positioning

Information if requested after the examination

Complete 11-minute examination procedure

Safety glance before touching the patient

Introduction, identity, explanation and consent

Hand hygiene, pain check, positioning and exposure

General inspection from the end of the bed

Hands, peripheral perfusion and pulse

Face and mouth

Carotid pulse and jugular venous pressure

Precordial inspection and palpation

Cardiac auscultation and focused maneuvers

Respiratory examination for pulmonary congestion

Peripheral edema and lower-limb perfusion

Abdominal signs of systemic congestion

Complete the patient encounter respectfully

Present the findings concisely

Diagnosis, prioritized investigations, management and safety net

Physical findings

Examiner prompts

Self-assessment checklist

Differential diagnosis

Investigations

Management

Communication behaviours

Critical safety actions

Model closing summary

Common pitfalls

Reference starting points

Choose another complete 11-minute station