How to Do a Cardiovascular Examination for NRE Step 2 OSCE 2026

A candidate approaches the cardiovascular OSCE station, introduces himself, and goes straight to the patient’s chest with his stethoscope. He auscultates for 90 seconds, identifies a murmur, and presents his findings confidently. He scores 8 out of 20 marks.

The cardiovascular examination station in NRE Step 2 is not just about listening to the heart. It is a structured assessment that begins at the patient’s hands, moves systematically to the face, neck, and precordium, and ends with a clear verbal presentation of findings. An examiner’s mark sheet for cardiovascular examination typically contains 18–22 individual checkpoints. A candidate who skips the peripheral examination and goes straight to auscultation misses half those marks before placing the stethoscope on the chest.

This guide walks through the complete cardiovascular examination sequence for NRE Step 2 — every step, what each finding means, and the specific points examiners mark.

The Complete Cardiovascular Examination — Step by Step

• 1
  Wash Hands, Introduce, Obtain Consent, Position Perform hand hygiene visibly. Introduce: “My name is Dr. [name]. I’ve been asked to examine your heart today — is that alright?” Position the patient at 45° (important — JVP is assessed at this angle). Expose the chest adequately — male: fully exposed; female: use a gown/towel to preserve dignity while allowing access. Request a chaperone for female patients: “I would normally ask for a chaperone to be present.”
• 2
  General Inspection — From the End of the Bed Stand back. Observe: does the patient look well or unwell? Breathless at rest? Cachexic (endocarditis, chronic heart failure)? Cyanosed (central — lips and tongue blue; peripheral — fingertips blue)? Malar flush (mitral stenosis — flushed cheeks due to low cardiac output)? Visible pacemaker or defibrillator bulge under the skin? Surgical scars on the chest (sternotomy — previous cardiac surgery)? Note any oxygen, IV lines, monitoring equipment.
• 3
  Hands — Peripheral Signs Inspect both hands: Clubbing (loss of nail fold angle — infective endocarditis, congenital cyanotic heart disease, pulmonary causes); Splinter haemorrhages (linear subungual haemorrhages — infective endocarditis; also trauma — distinguish by distribution: traumatic = dominant hand distal nails; endocarditis = multiple fingers); Osler’s nodes (painful nodules on finger pulps — infective endocarditis); Janeway lesions (painless erythematous macules on palms/soles — infective endocarditis); Xanthomata (yellow-white deposits over tendons — hypercholesterolaemia); Peripheral cyanosis (blue fingertips — poor peripheral perfusion or Raynaud’s); Tar staining (smoking — cardiovascular risk factor); capillary refill time (>2 seconds = poor perfusion).
• 4
  Radial Pulse — Rate, Rhythm, Character Use 3 fingers (index, middle, ring) over the radial pulse at the wrist. Count for a full 30 seconds and multiply by 2 (or 60 seconds if irregular). Assess: Rate (normal 60–100 bpm); Rhythm (regular / regularly irregular [ectopics] / irregularly irregular [AF]); Volume (normal / bounding [aortic regurgitation, CO₂ retention, thyrotoxicosis] / weak/thready [shock, aortic stenosis, tamponade]); Character (slow-rising plateau = aortic stenosis; collapsing/water-hammer = aortic regurgitation — feel with fingers elevated). Then assess for radio-radial delay (simultaneous palpation of both radial pulses — delay = subclavian artery stenosis or aortic coarctation) and radio-femoral delay (simultaneous radial and femoral — delay = coarctation of the aorta).
• 5
  Blood Pressure State: “I would like to measure the blood pressure in both arms.” In the exam you may be told the BP or asked to demonstrate the technique. A difference of >20 mmHg systolic between arms = subclavian stenosis or aortic dissection. Postural BP drop (>20 mmHg systolic on standing) = postural hypotension — causes: dehydration, autonomic neuropathy (DM), medications (antihypertensives, diuretics).
• 6
  Face — Eyes, Mouth Eyes: Corneal arcus (white ring around cornea — hypercholesterolaemia; normal if age >60); Xanthelasma (yellow plaques on eyelids — hypercholesterolaemia); Pale conjunctivae (anaemia — pull down lower lid); Jaundice (scleral icterus — haemolytic anaemia from valve-related haemolysis or right heart failure causing hepatic congestion); Roth spots (flame-shaped retinal haemorrhages with pale centres — infective endocarditis — mention that fundoscopy would be performed). Mouth: Cyanosis (central — blue tongue and lips); High-arched palate (Marfan syndrome — associated with aortic regurgitation and dissection); Dental hygiene (poor dentition = risk factor for infective endocarditis).
• 7
  Jugular Venous Pressure (JVP) Patient at 45°. Turn head slightly to the left. Identify the internal jugular vein pulsation in the right neck (lateral to sternocleidomastoid — NOT the carotid artery). Distinguish JVP from carotid: JVP is non-pulsatile on palpation, has a double waveform (a and v waves), falls on inspiration, and rises with abdominal pressure (hepatojugular reflux). Measure height: normal JVP = <4 cm above the sternal angle at 45°. Raised JVP = right heart failure, cardiac tamponade, SVC obstruction, fluid overload. State: “The JVP is raised at [X] cm above the sternal angle” or “The JVP is not raised.”
• 8
  Carotid Pulse — Character Palpate the carotid pulse gently with one finger at a time (never both simultaneously — risk of syncope). Assess character: slow-rising (aortic stenosis), collapsing (aortic regurgitation), bisferiens (mixed AS + AR). Auscultate over the carotid for bruits (turbulent flow — carotid stenosis or radiation of aortic stenosis murmur).
• 9
  Precordium — Inspection Inspect the chest: Scars — median sternotomy (CABG, valve replacement); left lateral thoracotomy (mitral valvotomy); pacemaker/ICD pocket (usually left infraclavicular). Visible apex beat (hyperdynamic circulation — anaemia, thyrotoxicosis, AR). Visible pulsations — left parasternal heave visible in RV enlargement. Deformities — pectus excavatum (associated with MVP and Marfan syndrome).
• 10
  Precordium — Palpation Apex beat: Use the flat of the hand first to locate, then fingertips to define. Normal position: 5th intercostal space, midclavicular line. Displaced apex = cardiomegaly (left ventricular enlargement moves apex inferolaterally). Character: forceful/thrusting (volume overload — AR, MR); heaving/sustained (pressure overload — AS, hypertension); tapping (palpable S1 — mitral stenosis); diffuse/dyskinetic (left ventricular aneurysm post-MI). Heaves: Left parasternal heave (right ventricular hypertrophy — pulmonary hypertension, pulmonary stenosis). Thrills: Palpable murmurs — feel with the flat of the hand in all 4 areas. A palpable thrill = grade 4+ murmur.
• 11
  Auscultation — 4 Areas in Sequence Use the diaphragm first (high-pitched sounds), then the bell (low-pitched sounds — mitral stenosis rumble). Auscultate in sequence: Mitral area (apex — 5th ICS MCL); Tricuspid area (lower left sternal edge — 4th ICS); Pulmonary area (upper left sternal edge — 2nd ICS); Aortic area (upper right sternal edge — 2nd ICS). Listen for: heart sounds (S1, S2 — loud/soft/split?), added sounds (S3 gallop = heart failure; S4 = hypertensive/ischaemic heart disease), murmurs (systolic vs diastolic, grade, character, radiation). Turn patient: left lateral for mitral stenosis (bell at apex); sitting forward + breath held in expiration for aortic regurgitation (early diastolic murmur at lower left sternal edge).
• 12
  Lung Bases — Check for Pulmonary Oedema Percuss and auscultate the lung bases posteriorly. Fine bibasal crepitations (crackles that do not clear with coughing) = pulmonary oedema (left heart failure). Dull bases with reduced breath sounds = pleural effusion (can occur in heart failure). Examiners mark whether you complete this step — many candidates stop after cardiac auscultation.
• 13
  Sacral and Ankle Oedema Press firmly over the sacrum (if patient can sit forward — best site for dependent oedema in bed-bound patients) and over both ankles. Pitting oedema leaves an impression lasting >15 seconds. Grade by extent: ankle only / up to knee / up to thigh. Bilateral pitting oedema = right heart failure, hypoalbuminaemia (nephrotic, liver disease), or venous insufficiency. Examiners specifically mark whether you check both sacral and ankle oedema.
• 14
  Hepatomegaly — Hepatojugular Reflux Press firmly on the right upper quadrant for 10–15 seconds while observing the JVP. A rise of >4 cm in JVP = positive hepatojugular reflux = elevated right-sided filling pressures (right heart failure). Also palpate for tender hepatomegaly (congestive hepatopathy from right heart failure — “nutmeg liver”).
• 15
  Peripheral Pulses and Completion State: “To complete my cardiovascular examination I would also like to check all peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibial), measure the blood pressure in both arms, perform fundoscopy (for hypertensive/diabetic changes and Roth spots), check the temperature chart, and review the 12-lead ECG and chest X-ray.” Thank the patient, help them re-dress, wash hands.

Murmur Identification — The NRE Examiner’s Most Common Question

After completing auscultation, the examiner will almost always ask: “What murmur did you hear?” or “What do you think the diagnosis is?” Know this murmur table completely — it covers the conditions that appear in NRE cardiovascular OSCE stations.

Peripheral Signs — What Each Finding Tells You

Most Common Examiner Marks Lost in Cardiovascular Station

• ✗ Going straight to the chest without examining hands, face, and neck first — misses 6–8 marks
• ✗ Counting the radial pulse for only 10–15 seconds — inaccurate rate, cannot detect irregular rhythms
• ✗ Forgetting to measure or mention blood pressure
• ✗ Not assessing JVP — one of the most consistently marked steps
• ✗ Auscultating in only 2 areas instead of all 4 standard areas
• ✗ Not listening with the patient in left lateral position (misses mitral stenosis rumble)
• ✗ Not auscultating the lung bases (pulmonary oedema detection)
• ✗ Not checking for sacral and ankle oedema
• ✗ Stating “there is a murmur” without grading it, locating it, or identifying radiation
• ✗ Not completing the examination with a verbal summary and investigation plan
• ✓ State findings out loud throughout — examiners mark what they can observe
• ✓ Present murmurs with grade, location, character, radiation, and diagnosis
• ✓ Always check lung bases and peripheral oedema — never stop at the precordium
• ✓ Complete with: “To complete my examination I would also like to…”

Frequently Asked Questions