MRCS Part B Revision · Physical examination
Cardiovascular — MRCS Part B Physical examination
By Dr Richard Miller, MBChB FRCS · Reviewed
Cardiovascular is a physical examination station. Three of the seventeen examined stations in the MRCS Part B OSCE are physical examination. The physical examination stations ask you to examine a real patient or a simulated one to a clear sequence, interpret what you find, and present it.
What you need to know for the Cardiovascular station
With all examinations first expose the patient, then inspect and examine before going on to comment on important additional points. Thank the patient, and offer the help them get dressed.
Pre-operative assessment is a way of risk assessing patients on a case by case basis. See NICE guielines on which investigations are required for which grade of surgery.
Heart failure is a significant perioperative risk factor which if present doubles the risk of death after major surgery.
General Inspection
Look around bed for: medication, oxygen, insulin, chest leads, walking aids, medical-alert bracelet.
Does the patient look: well, breathless, well nourished. Any recognisable syndrome, how is the patient’s complexion?
Exposure
Strip to the waist; 45 sitting upright
Use bed sheet to maintain patient’s dignity while examining other systems.
Hands
Inspect dorsal and palmar aspects noting colour, skin texture, deformities and feel for temperature or sweating.
Fingers: tar-staining, finger clubbing, lipid deposits (xanthomata), palmar erythema, Dupryten’s, Osler’s nodes and Janeway lesions (Infective endocarditis).
Nails: koilonychias (spoon-shaped nail in iron deficiency), onycholysis (destruction), Beau’s lines (chronic disease), Mee’s lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), pitting (psoriasis/alopecia) and capillary nailbed pulsation (Quinke’s sign of aortic regurge).
Pulse
Palpate the radial pulses and check for radial-radial delay and raise the arm up and feeling for collapsing pulse while gripping wrist
Blood Pressure
Size the cuff and position the relaxed arm at the level of the heart
Inflate cuff till brachial pulse is occluded for maximum inflation pressure then deflate. Wait 15-20 seconds.
Listen with the diaphragm and inflate cuff then gradually deflate at rate of 2mmHg/second
Note B.P. to 2mmHg
Jugular Venous Pressure
Pt slightly looking to the left
Shine light/torch
Note cm above angle of Louis (normal =3cm)
Face
Eyes: Looking for anaemia, jaundice, corneal arcus, Kayser-Fleischer rings (Cu deposits, Wilson,s disease), xantholasma
Cheeks: Malar flush (mitral stenosis)
Mouth: Looking for central cyanosis, angular chelitis
Carotid pulse
Character & Volume: bounding pulses (CO2 retention, liver failure, sepsis), small volume (aortic stenosis, shock, pericardial effusions), collapsing (aortic incompetence, AV malformations, PDA), slow-rising (aortic stenosis), bisferiens (aortic stenosis+regurge), pulsus alternans ( strong then weak - LVF, AS, cardiomyopathy), pulsus paradoxus (systolic weakens with inspiration - severe asthma, pericardial constriction, tamponade).
Thorax
Inspection
Praecordium for scars (look in apex) and ask patient to identify, implantable devices, colour, surface vessels, muscular deformity, breathing.
Assess capillary refill by pressing on the chest
Palpation
Apex Beat: Hand below nipple feeling for maximal impulse then pinpoint midclavicular line 5th intercostal space and note the character.
Heave: palm on left sternal edge (thrusting pulsation indicating right ventricular enlargement)
Thrill: palm over aortic/pulmonary area (palpable murmur)
Auscultation
Place your finger on the carotid and listen at the mitral area (apex) with diaphragm and bell. Listen over the mitral area with the bell in left lateral position asking the patient to hold their breath to accentuate any murmurs.
Place the diaphragm over the tricuspid (5th IC left sternal edge), pulmonary (2nd IC left manubrial edge) and aortic (2nd IC right manubrial edge) areas.
Listen with the bell over the carotids.
Identify 1st and 2nd heart sounds, listen for added sounds and murmurs.
Murmurs
Inspiration accentuates right sided murmurs, expiration accentuates left sided murmurs.
Character: ejection-systolic (AS), pansystolic (MR), early-diastolic (AR), mid-diastolic (MS).
Radiation: ESM of AS radiate to carotids, PSM of MR to axilla.
Intensity: Graded systolic 1-6, diastolic 1-4.
1/6 Very soft
2/6 Soft but immediately detectable
3/6 Clearly audible, no thrill
4/6 Clearly audible, palpable thrill
5/6 Audible with stethoscope partially touching chest
6/6 Heard without stethoscope
Peripheral Pulses
Palpate popliteal (behind knee), posterior tibial (behind medial malleolus) and dorsalis pedis (1st/2nd metatarsals on anterior ankle) pulses.
Check for pitting oedema at feet and expose legs to look for vein harvest sites if you have not already done so.
Top Tips
Pre-operative assessment is a common scenario in the MRCS OSCE examination. It is seen as a relatively straightforward station, but don’t be lured into a false sense of security. Show the examiner you have a clear structure and work through it methodically.
Whilst in reality an anaesthetic review might be sought you will be expected to review and comment upon investigation results such as an ecg, be systematic in your approach to interpreting these (rate, rhythm, etc).
Be cautious not to just reel off a list of tests and investigations without having good reasoning for doing them.
References:
1. NICE guidance Preoperative tests for elective surgery. nice.org.uk/guidance/cg3
2. http://bestpractice.bmj.com/best-practice/monograph/954.html
What are you asked at the Cardiovascular station?
The station runs to 12 questions over nine minutes. These are the questions as they are put to you; the model answers are in the question bank.
- The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this patient’s cardiovascular system and discuss and review any relevant investigations you wish to perform prior to surgery. Examination: CVS A
- Explain how you would introduce yourself
- Explain how you would expose this gentleman and how you would begin your examination
- Describe your inspection findings
- What would you do after inspection?
- This gentleman is comfortable at rest, he has a well-healed scar from a median sternotomy, and scars on the lower limbs consistent with vein harvesting for a coronary artery bypass graft. There are no stigmata of cardiac failure. What is your differential diagnosis?
- How will you manage the patient?
- What investigations will you request?
- What will a transthroacic ECHO tell you?
- What are the benefits of good pre-operative assessment prior to elective surgery?
- Do you know a system for grading patients prior to surgery?
- What are the limitations of the ASA system?
How is the physical examination station marked in MRCS Part B?
A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
FAQ
What does the Cardiovascular station ask?
It opens with "The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this patient’s cardiovascular system and discuss and review any relevant investigations you wish to perform prior to surgery. Examination: CVS A" and runs to 12 questions over nine minutes. A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
How many examination stations are there in MRCS Part B?
Three of the seventeen examined stations are physical examination. The number was reduced from four when the exam moved from eighteen stations to seventeen, implemented from the October 2020 diet.
How is a physical examination station marked?
Out of 20, with 8 marks for clinical and technical skill and 4 each for knowledge, communication and professionalism. The station also receives a global rating of pass, borderline or fail.
When do I present my findings?
At six minutes of the nine you are signalled to present. Rehearse the examination to finish inside six minutes, because the presentation carries marks that a rushed or truncated one will not earn.
How many stations are in the MRCS Part B OSCE?
Seventeen examined stations of nine minutes each, with a minute to read the task before each one. Two preparation stations and at least one rest station bring the circuit to about twenty, and the exam takes about three and a half hours.
What is the pass mark for MRCS Part B?
There is no published pass mark. The cut score is set separately for Applied Knowledge and Applied Skills, for each circuit, by borderline regression. Published pass rates across the 2024/25 diets ranged from 51% to 66%.
Can I fail a station and still pass?
Yes. There is no rule about how many stations you may fail: the cut score applies to your total mark in each component, so a weak station costs the marks you lost on it and strong stations elsewhere can make them back. Applied Knowledge and Applied Skills are passed separately and must both be passed at the same sitting, so a strong anatomy performance cannot rescue a weak communication one.
Dr Richard Miller, MBChB FRCS
Station summaries are reviewed against the current intercollegiate MRCS syllabus and the published marking blueprint. Guidance changes between diets: check the royal colleges' own pages before relying on a date, a fee or a threshold.
Practise this station
The question bank carries the model answer to every question above, with the rest of the physical examination stations.
More physical examination stations