Heart Failure Examination OSCE Checklist

1. Preparation

• Hand hygiene
• Introduce yourself, confirm patient identity
• Explain examination and obtain consent
• Offer chaperone
• Ask about pain or breathlessness and position patient at 45°
• Expose from waist to knees while maintaining dignity

2. General inspection

• Breathlessness, inability to lie flat
• Oxygen, IV lines, diuretics, GTN infusion, monitoring
• Cyanosis, pallor, cachexia
• Peripheral edema
• Evidence of previous cardiac surgery, such as sternotomy scar
• Fluid balance chart or medications if available

3. Hands and arms

• Peripheral cyanosis
• Capillary refill time and peripheral temperature
• Pulse: rate, rhythm, volume
• Collapsing pulse if significant aortic regurgitation suspected
• Tremor, nicotine staining
• Radial-radial delay
• Measure blood pressure

4. Face

• Conjunctival pallor
• Central cyanosis
• Xanthelasma or corneal arcus
• Dentition, if infective endocarditis is a concern

5. Neck

• Assess JVP at 45°:
  • Height
  • Waveform
  • Hepatojugular or abdominojugular reflux
• Check carotid pulse, one side at a time
• Listen for carotid bruits only if appropriate

6. Precordium

• Scars: sternotomy, pacemaker/ICD, thoracotomy
• Visible apex beat or heaves

• Apex beat: location and character
  • Displaced, diffuse apex suggests cardiomegaly/LV dilatation
• Parasternal heave: right ventricular hypertrophy or pulmonary hypertension
• Thrills

• S1 and S2
• S3 gallop: suggests volume overload and systolic dysfunction
• S4: stiff ventricle, e.g. hypertensive heart disease
• Murmurs:
  • Mitral regurgitation may cause or worsen HF
  • Aortic stenosis is an important cause
  • Tricuspid regurgitation may accompany right-sided failure

7. Lungs

• Inspect respiratory effort and rate
• Percuss lung bases for pleural effusion
• Auscultate posteriorly for:
  • Bibasal fine crackles
  • Wheeze, sometimes termed cardiac asthma
  • Reduced air entry and dullness at bases from pleural effusions

8. Abdomen

• Inspect for distension
• Palpate for tender hepatomegaly
• Assess for ascites
• Consider abdominal aortic aneurysm palpation if relevant

9. Legs and sacrum

• Check for bilateral pitting edema:
  • Ankles in mobile patients
  • Sacrum in bedbound patients
• Assess peripheral pulses
• Look for chronic venous insufficiency, ulcers, or signs suggesting an alternative cause of edema

10. Complete the examination

“To complete my assessment, I would check the observations and fluid balance, review the ECG, chest radiograph, echocardiogram, BNP/NT-proBNP, renal function, electrolytes, full blood count, liver function, thyroid function, and urinalysis. I would also perform a focused neurological and peripheral vascular examination where indicated.”

OSCE summary statement

“This patient has clinical features of heart failure with congestion, including [raised JVP / bibasal crackles / peripheral edema / displaced apex / S3]. I would assess whether this is acute or chronic, identify a precipitant such as ischemia, arrhythmia, infection, uncontrolled hypertension, medication non-adherence, renal impairment, or valvular disease, and arrange urgent management if they are hypoxic, hypotensive, or in pulmonary edema.”

Red flags requiring urgent escalation

• Severe respiratory distress or hypoxia
• Pink frothy sputum
• Hypotension, confusion, cold peripheries
• New chest pain or suspected acute coronary syndrome
• New rapid atrial fibrillation or other unstable arrhythmia
• Markedly reduced urine output