Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
Learning Objectives
- Examination Skills: Demonstrate a systematic cardiovascular examination (Inspection, Palpation, Auscultation) and manual blood pressure measurement.
- Clinical Technique: Correct use of the analogue sphygmomanometer and anatomical positioning.
- Communication: Effectively explaining the physical exam steps to the patient and addressing concerns.
Patient Profile
- Name: Mr. George Papadopoulos
- Age: 58 years old
- Ethnicity: Greek-Australian
- Occupation: Warehouse Manager
- Social History: History of smoking (20 pack-years, quit 2 years ago). Sedentary lifestyle. Occasional alcohol use.
Presenting Complaint
Mr. Papadopoulos presents for a follow-up appointment after a “health screening” at work indicated his blood pressure was “a bit high.” He has also been feeling “a bit more tired than usual” when climbing stairs.
Contextual Information
- History of Presenting Complaint (HPC): No chest pain or orthopnoea. Admits to mild exertional dyspnoea (NYHA Class II).
- Past Medical History (PMH): Hyperlipidaemia (diagnosed 5 years ago), non-compliant with diet. No previous surgeries.
- Medications: Atorvastatin 20mg (occasional use).
- Allergies: No known drug allergies.
- Family History: Father died of an Acute Myocardial Infarction at age 62.
Exam Instructions
Candidate Instructions
- Perform a focused Cardiovascular Examination on Mr. Papadopoulos.
- Perform a manual blood pressure measurement using the provided analogue equipment.
- Report your findings to the examiner.
- Briefly explain your findings to the patient and discuss the next steps.
Standardised Patient (SP) Instructions
- Demeanour: Generally cooperative but slightly anxious about “heart trouble” given your family history.
- Key Concerns: “Do you think I’m going to have a heart attack like my dad?”
- Physical state: You are already wearing a gown; your chest is ready for exposure.
- During BP measurement: If the candidate is rough with the cuff or the pump, mention it feels “a bit tight” or “uncomfortable.”
Examiner Checklist Items
- [ ] WIPE: Washes hands, Introduces, asks for Permission, ensures Exposure.
- [ ] Positioning: Ensures the patient is at a 45-degree semi-sitting angle.
- [ ] Peripheral Signs (1.5 mins): Checks hands (clubbing, stains), eyes (xanthelasma), and JVP.
- [ ] BP Technique:
- Places cuff 1-2cm above cubital fossa.
- Hooks dial to the cuff strap.
- Uses thumb and index finger on the screw.
- Performs palpatory method before auscultation.
- [ ] Precordium (3.5 mins):
- Inspects for scars/deformities.
- Palpates Apex Beat (5th ICS, MCL), checks for heaves/thrills.
- Auscultates 4 valves (Mitral, Tricuspid, Pulmonary, Aortic) with bell and diaphragm.
- [ ] Reporting: Correctly identifies S1, S2, and presence/absence of murmurs.
Key Clinical Findings
- Vital Signs: HR 78 bpm (regular), RR 14 bpm.
- BP: 155/95 mmHg (Manual).
- Peripheral: No splinter haemorrhages or clubbing. JVP is not elevated (3cm).
- Precordial: Apex beat is in the 5th intercostal space, mid-clavicular line (not displaced). No heaves or thrills.
- Auscultation: S1 and S2 heard. No murmurs, rubs, or gallops. Lungs are clear at the bases.
Communication Triggers (Murtagh’s Approach)
- Open-ended start: “Before I begin the physical exam, what are your main concerns regarding your health today?”
- Signposting: “I’m going to start by looking at your hands and eyes, then I’ll move to your chest to listen to your heart.”
- Empathy: “It’s understandable that you’re worried given what happened to your father. We are doing these checks today to manage your risks early.”
- Summarising: “So, your heart sounds are normal today, but your blood pressure is indeed elevated. We should talk about a plan to monitor this.”
Assessment & Marking Guide
| Criteria | Fail | Pass | Excellent |
| Systemic Sequence | Disorganized; missed positioning or WIPE. | Follows WIPE; positions at 45°; checks periphery and core. | Highly efficient; finishes within 8 minutes with clear transitions. |
| Technical Skill (BP) | Incorrect cuff placement; no palpatory step. | Accurate cuff placement; uses dial hook; steady deflation. | Demonstrates superior manual dexterity with the screw and dial. |
| Clinical Findings | Fails to locate apex beat or name valves. | Locates apex beat; identifies S1/S2; reports BP accurately. | Correlates findings (e.g., normal S1/S2) with patient’s stable status. |
| Patient-Centeredness | Ignores SP’s anxiety; uses jargon. | Addresses “dad” concern; uses lay language. | Validates emotions; uses Murtagh’s “The Diagnostic Model” logic. |
Sample Answers / Model Performance
History & Introduction
“Mr. Papadopoulos, I’ll be performing a heart examination today. This involves checking your pulse, blood pressure, and listening to your heart valves. Is that okay? First, what is the biggest concern you have about your heart right now?”
Explaining the BP Technique
“I’m going to wrap this cuff around your arm, just about two finger-widths above your elbow. I’ll be feeling your pulse first while I pump it up, then I’ll listen with the stethoscope as I let the air out very slowly. You’ll feel a bit of pressure, but it will be brief.”
Reporting Findings to Examiner
“On examination of Mr. Papadopoulos, he is comfortable at 45 degrees. There are no peripheral stigmata of cardiovascular disease. JVP is not raised. On precordial exam, the apex beat is not displaced. S1 and S2 are normal with no added sounds or murmurs. Manual blood pressure is 155/95 mmHg.”
Explaining the Plan to Patient
“George, the good news is that your heart sounds very healthy and strong. However, your blood pressure is higher than we would like it to be. Given your family history, I’d like to see you again next week and perhaps have you keep a diary of your blood pressure at home. How does that sound to you?”