11/13/24, 6\:55 PM Guide | Aortic stenosis examination

Aortic stenosis examination

Table of contents

Background

In OSCE scenarios, you may be asked to perform a focused examination to determine the presence (or absence) of a certain
condition. In order to do this, you need to be comfortable with the relevant basic system examination (i.e. for an aortic stenosis
examination you need to be comfortable with performing a cardiovascular examination).
Aortic stenosis (AS) refers to a tightening of the aortic valve at the origin of the aorta.

Aetiology

AS has a number of potential causes including\:
Calci
adults.
Congenital abnormality of the aortic valve\: the aortic valve is normally composed of three cusps (known as a tricuspid
valve), but in some cases, individuals have only two cusps (known as a bicuspid valve) which predisposes them to the
development of AS as well as aortic regurgitation.
Rheumatic heart disease\: a rare cause of AS in developed countries.
When examining a patient with suspected AS you should look for clinical features of aortic stenosis and its potential underlying
causes.

Clinical features of aortic stenosis

Aortic stenosis typically presents with the following triad of symptoms (use the mnemonic SAD to remember them)\:
Syncope (exertional)
Angina
Dyspnoea

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle and ask the patient to lay on the bed.
Adequately expose the patient’s chest for the examination (o
appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess
for peripheral oedema and signs of peripheral vascular disease.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 1/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Cyanosis\: a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath\: may indicate underlying cardiovascular disease (e.g. aortic stenosis with secondary left ventricular
hypertrophy).
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion
(e.g. congestive cardiac failure).
Malar
heart disease).
Oedema\: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes
of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit.
Bruising\: may indicate recent falls secondary to syncope.

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note
volume/colour of urine) and intravenous access.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Pillows\: patients with congestive heart failure typically su
As a result, they often use multiple pillows to prop themselves up.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their
physiological parameters have changed over time.
Fluid balance\:
patient appears
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.
General inspection
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 2/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspection

General observations
Inspect the hands and note your
Colour\: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying
hypoxaemia.
Tar staining\: caused by smoking, a signi
disease, hypertension).
Xanthomata\: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow.
Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for
cardiovascular disease (e.g. aortic stenosis, coronary artery disease, hypertension).

Palpation

Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Capillary re
Measuring capillary re
Apply
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two
seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure)
and the need to assess central capillary re
Inspect the palms

Pulses and blood pressure

https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 3/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination

Radial pulse

Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.

Brachial pulse

Palpate the brachial pulse
Palpate the brachial pulse in their right arm, assessing volume and character\:
1. Support the patient's right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.
Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.
Types of pulse character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation and also CO 2
retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)

Blood pressure

Measure the blood pressure
Measure the patient's blood pressure in both arms (see our blood pressure guide for more details).
Blood pressure abnormalities
Blood pressure abnormalities may include\:
Hypertension\: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal
to 150/90 mmHg if you're over 80 years old).
Hypotension\: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure\: less than 25 mmHg of di
include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure\: more than 100 mmHg of di
include aortic regurgitation and aortic dissection.
Di
suggest aortic dissection.

Carotid pulse

The carotid pulse can be located between the larynx and the anterior border of the sternocleidomastoid muscle.
Auscultate the carotid artery
Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a
bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a
carotid plaque and causing an ischaemic stroke.
Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle
over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 4/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Be aware that at this point in the examination, the presence of a 'carotid bruit' may, in fact, be a radiating cardiac murmur (e.g.
aortic stenosis).
Palpate the carotid pulse
If no bruits were identi
1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing re
artery (potentially causing a syncopal episode).
2. Gently place your
carotid pulse.
3. Assess the character (e.g. slow-rising in aortic stenosis) and volume of the pulse.
Palpate the radial pulse

Jugular venous pressure (JVP)

In a focused examination for aortic stenosis, assessment of the JVP is performed to screen for evidence of right heart failure,
which commonly occurs secondary to left heart failure (e.g. due to excessive afterload in aortic stenosis).
Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal
jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The
presence of this continuous column of blood means that changes in right atrial pressure are re
atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid,
making it di
sternocleidomastoid muscle).
Because of the inability to easily visualise the IJV, it's tempting to use the external jugular vein (EJV) as a proxy for assessment
of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the
subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous
pressure.

Measure the JVP

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 5/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the
sternocleidomastoid. The IJV has a double waveform pulsation, which helps to di
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV
(in healthy individuals, this should be no greater than 3 cm).
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include\:
Right-sided heart failure\: commonly caused by left-sided heart failure (e.g. secondary to aortic stenosis). Pulmonary
hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary
disease or interstitial lung disease.
Tricuspid regurgitation\: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis\: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying
causes.
Assess the JVP

Eyes

Inspect the eyes for signs relevant to aortic stenosis
Corneal arcus\: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over
the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50
suggests underlying hypercholesterolaemia (increased risk of aortic stenosis).
Xanthelasma\: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia (increased
risk of aortic stenosis).
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 6/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Inspect the eyes

Close inspection of the chest

Closely inspect the anterior chest

Look for clinical signs that may provide clues as to the patient's past medical/surgical history\:
Scars suggestive of previous thoracic surgery\: see the thoracic scars section below.
Pectus excavatum\: a caved-in or sunken appearance of the chest.
Pectus carinatum\: protrusion of the sternum and ribs.
Visible pulsations\: a forceful apex beat may be visible secondary to underlying ventricular hypertrophy (e.g. aortic stenosis).
Thoracic scars
Median sternotomy scar\: located in the midline of the thorax. This surgical approach is used for cardiac valve
replacement and coronary artery bypass grafts (CABG).
Anterolateral thoracotomy scar\: located between the lateral border of the sternum and the mid-axillary line at the
th th
4 or 5 intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
Infraclavicular scar\: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker
insertion.
Left mid-axillary scar\: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-
de
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 7/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Inspect for thoracic scars

Palpation

Palpate the chest to assess the location of the apex beat and to identify heaves or thrills.

Apex beat

Palpate the apex beat with your
In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their
breast to allow palpation of the appropriate area if relevant.
Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy.
The apex beat in aortic stenosis may be displaced due to ventricular hypertrophy.

Heaves

A parasternal heave is a precordial impulse that can be palpated.
Place the heel of your hand parallel to the left sternal edge (
If heaves are present you should feel the heel of your hand being lifted with each systole.
Parasternal heaves are typically associated with right ventricular hypertrophy.

Thrills

A thrill is a palpable vibration caused by turbulent blood
You should assess for a thrill across each of the heart valves in turn (see valve locations below).
To do this place your hand horizontally across the chest wall, with the
assessed.
In the context of aortic stenosis, a systolic thrill may be palpable over the aortic valve.
Valve locations
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve\: 2nd intercostal space at the left sternal edge.
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 8/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Aortic valve\: 2nd intercostal space at the right sternal edge.
Palpate the apex beat

Auscultation

Auscultate the four heart valves

A systematic routine will ensure you remember all the steps whilst giving you several chances to listen to each valve area. Your
routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps. Ask
the patient to lift their breast to allow auscultation of the appropriate area if relevant.
1. Palpate the carotid pulse to determine the
2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the
carotid pulse\:
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve\: 2nd intercostal space at the left sternal edge.
Aortic valve\: 2nd intercostal space at the right sternal edge.
3. Repeat auscultation across the four valves with the bell of the stethoscope.
Accentuation manoeuvres
Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for
radiation of an ejection systolic murmur caused by aortic stenosis.
Typical
Aortic stenosis is associated with an ejection systolic murmur heard loudest over the aortic valve. The murmur is described as
having a ‘crescendo-decrescendo’ quality (it appears as diamond-shaped on a phonogram). The murmur of aortic stenosis
commonly radiates to the carotid arteries.
Levine murmur grading scale
Grade 1\: a very faint murmur which is only audible during prolonged auscultation.
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 9/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Grade 2\: a faint murmur, immediately audible with a stethoscope.
Grade 3\: a loud murmur with NO thrill.
Grade 4\: a loud murmur WITH a thrill.
Grade 5\: a loud murmur WITH a thrill, heard with only half of the stethoscope touching the chest.
Grade 6\: a loud murmur WITH a thrill, heard WITHOUT the stethoscope touching the chest.
You will not be expected to grade a murmur, but it is useful to have a basic understanding of the scale.
Palpate the carotid pulse to identify the

Final steps

Posterior chest wall

Auscultation
Auscultate the lung
Coarse crackles are suggestive of pulmonary oedema (e.g. secondary to left ventricular failure).
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural e
ventricular failure).

Sacral oedema

Inspect and palpate the sacrum for evidence of pitting oedema.

Legs

Inspect and palpate the patient's ankles for evidence of pitting pedal oedema (associated with right ventricular failure).
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 10/1111/13/24, 6\:55 PM Guide | Aortic stenosis examination
Auscultate the posterior lung

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 6 4- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
t h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
"
" T h e h a n d s h a d n o p e r i p h e r a l s t i g m a t a o f c a r d i o v a s c u l a r d i s e a s e a n d w e r e s y m m e t r i c a l l y w a r m , w i t h a n o r m a l c a p i l l a r y
r e
"
" T h e p u l s e w a s r e g u l a r w i t h a s l o w-r i s i n g c h a r a c t e r .
"
" O n i n s p e c t i o n o f t h e f a c e , c o r n e a l a r c u s w a s n o t e d .
"
" A s s e s s m e n t o f t h e J V P d i d n o t r e v e a l a n y a b n o r m a l i t i e s .
"
" C l o s e r i n s p e c t i o n o f t h e c h e s t d i d n o t r e v e a l a n y s c a r s o r c h e s t w a l l a b n o r m a l i t i e s . T h e a p e x b e a t w a s p a l p a b l e i n t h e
5 t h i n t e r c o s t a l s p a c e , i n t h e m i d-c l a v i c u l a r l i n e . A t h r i l l w a s n o t e d o v e r t h e a o r t i c r e g i o n .
"
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/clinical-examination/aortic-stenosis-examination/ 11/11