Cardiovascular System Examination — The Classic DCE Short-Case Routine

The answer first

The instruction "Please examine this patient's cardiovascular system" is the single commonest short case in the FRACP Divisional Clinical Examination, the MRCP PACES Station 3, and the ABIM clinical assessment. The examiner is not primarily testing diagnosis — the diagnosis is often deliberately straightforward. The examiner is testing whether the candidate can perform a complete, fluent, reproducible examination that follows a logical sequence, elicits every relevant sign, and then presents the findings in a structured, confident, hypothesis-driven way. The candidate who walks straight to the chest and listens has already failed the question. [1]

The reproducible routine, committed to muscle memory before the examination, is: [1]

1. End of bed — breathless, cyanosed, cachectic, Cushingoid, skeletal abnormalities (Marfanoid habitus), obvious scars and devices.
2. Hands — clubbing, peripheral stigmata of endocarditis, peripheral cyanosis, tendon xanthomata, the pulse (rate, rhythm, character).
3. Face — malar flush, dysmorphic features, dental caries, high arched palate.
4. Eyes — conjunctival pallor, xanthelasma, corneal arcus, hypertelorism, blue sclerae.
5. Neck — the jugular venous pressure (height and waveform), the carotid pulse (character and volume).
6. Praecordium — inspect (scars, visible impulses), palpate the apex beat (position and character), palpate for thrills and a right ventricular heave.
7. Auscultation — the four valve areas, diaphragm and bell, timing and character of every sound.
8. Dynamic manoeuvres — respiration, Valsalva, squat-to-stand, hand grip.
9. Back — basal crackles, pleural effusion.
10. Abdomen — hepatomegaly, pulsatile liver, ascites, splenomegaly.
11. Legs — peripheral oedema, peripheral pulses, deep vein thrombosis signs. [1]

The three principles that govern the whole encounter: [1]

• Sequence before sophistication. A complete, fluent, well-organised examination with a simple correct interpretation beats a brilliant but incomplete one. The examiner marks the routine first.
• Characterise the murmur by timing first. Timing is the single most reliable bedside discriminator. Systolic, diastolic, or continuous — then site, radiation, character, pitch, and the effect of dynamic manoeuvres [5].
• Present with a hypothesis. The presentation names the dominant finding, offers the anatomical and pathological diagnosis, and states the single investigation that confirms it. A list of unconnected observations is a fail; a synthesis is a pass.

DCE short-case trap: The candidate who walks to the chest and listens has committed the cardinal error — the cardiovascular examination begins at the end of the bed and ends at the legs, and the stethoscope is one instrument among many. The examiner has already formed a judgement before the candidate picks up the stethoscope. [1]

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1. [1]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2021.PMID 34447992
2. [2]Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association Eur J Heart Fail, 2021.PMID 33605000
3. [3]Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Circulation, 2021.PMID 33332150
4. [4]Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease Eur Heart J, 2022.PMID 34453165
5. [5]Etchells E, Bell C, Robb K Does this patient have an abnormal systolic murmur? JAMA, 1997.PMID 9032164
6. [6]Loeys BL, Dietz HC, Braverman AC, et al. The revised Ghent nosology for the Marfan syndrome J Med Genet, 2010.PMID 20591885