Anesthesiology APPLIED Exam › OSCE: echocardiography and POCUS

The 5 POCUS cardiac views

OSCE: echocardiography and POCUS·~5 min read· Physician-reviewed✓ Sourced · 4

Stem

Ultrasound application station, POCUS task. A healthy volunteer lies supine on the table, and the examiner is at the machine with a phased-array probe ready. The door prompt reads: "A 66-year-old man, 90 kg, is hypotensive in the PACU after an open colectomy. " The examiner will name one of the five transthoracic cardiac views for you to obtain in two and a half minutes; you hold the probe, and the examiner adjusts the machine on your instruction.

Question

Any of the five views could be the one I ask for. Where does the probe go for each, and how will you prove to me that it is the right view?

Ideal answer

HeadlineFor whichever of the five outline views you name,¹ I say the window, then the plane, then the anchor structures that prove it, before any finding.

Phased array, 1–5 MHz, cardiac preset, screen marker on the right.
Window and marker aloud: parasternal long-axis, left sternal border, third or fourth space, marker to the right shoulder.
Prove it with anchors: RV outflow tract on top, LV, mitral and aortic valves, descending aorta behind the left atrium.
Poor parasternal window: subcostal first, below the xiphoid, probe flat, aimed at the left shoulder.
Each view answers a question: is the LV squeezing, is the RV big, is there fluid around the heart, is the patient empty.

Breaking down the answer

Monitors-station loops and ultrasound tasks both use these views; window and plane first shows organization.

View	Probe position and marker	Identifying features	Main question it answers
Parasternal long-axis	Left sternal border, 3rd–4th space, marker to right shoulder	RVOT at top, LV, mitral and aortic valves, LA, descending aorta behind the LA	LV function, effusion versus pleural fluid, aortic root
Parasternal short-axis, mid-papillary	Same spot, rotate 90° clockwise, marker to left shoulder	Round LV with two papillary muscles, crescent RV	Global and regional LV function, septal "D" sign
Apical four-chamber	Point of maximal impulse, ~5th space, marker to the patient's left	Apex at top, four chambers, LV on the right of screen	RV:LV ratio, global function, valve color
Subcostal four-chamber	Below the xiphoid, probe flat, marker to the patient's left, aimed at left shoulder	Liver at top, RV nearest the probe, four chambers	Effusion, RV collapse, cardiac activity in arrest
Subcostal IVC	From subcostal four-chamber, rotate marker to the head	IVC entering the RA, hepatic vein joining	Volume status, RA pressure, plethora in tamponade

Parasternal long-axis: effusion versus pleural fluid — pericardial fluid tracks anterior to the descending aorta, between it and the heart; a left pleural effusion lies posterior and lateral.²
Parasternal short-axis: the septum — a "D" in diastole means RV volume overload; in systole as well, pressure overload: toward PE, RV infarction, pulmonary hypertension or RV failure, away from fluid.
Apical four-chamber: RV size — RV basal diameter over 41 mm is dilated;³ RV as large as or larger than the LV is severe. I look before fluid in a hypotensive patient with a high CVP.
Subcostal in the unstable patient — scanned in CPR pauses under 10 seconds without interfering with compressions; shows a large effusion and cardiac standstill.⁴
IVC measured correctly — 1–2 cm from the RA junction, supine, long axis, perpendicular to the vessel,³ not the aorta or a tangential cut for the cava. Every answer ends with what it changes: fluid, inotrope, drain or decompress.

Follow-up question

The examiner asks for the subcostal four-chamber view. Once you have it, the examiner says: your PACU patient has just had a central line placed, and in him this view shows a dark circumferential collection around the heart with the right ventricle folding in during diastole. What do you see, and what will you do?

Follow-up answer

Headline"Subcostal four-chamber; an anechoic circumferential collection; the right ventricle collapses in diastole." Tamponade, most likely from vessel or cardiac perforation.

I tell the team, give fluid, keep the rate up, avoid large tidal volumes, and prepare ultrasound-guided pericardiocentesis or surgical drainage, then reassess the chambers. The harder variant: the same dark space only in the parasternal long-axis, posterior to the descending aorta. That is a left pleural effusion, and the right answer is to say so rather than drain the pericardium.

Pitfalls that cost points

Calling a pleural effusion pericardial because I never looked for the descending aorta.
Measuring the aorta and calling it the IVC; the aorta is pulsatile, thick-walled and left of midline.
Judging RV size from a foreshortened apical view.⁴
Calling epicardial fat an effusion; fat is mostly anterior, brighter than myocardium, and moves with the heart.²

Rapid-fire

Q: Why is the subcostal window best during mechanical ventilation? A: Inflated lung covers the parasternal and apical windows, but the liver gives a fluid-filled path from below; parasternal and subcostal are easiest for non-experts to obtain reliably.⁴

Q: Which probe do I choose? A: Phased array, because its small footprint fits between ribs and its low frequency reaches 16–20 cm.

Q: How do I tell the IVC from the aorta? A: The IVC enters the RA, receives a hepatic vein, varies with respiration and lies to the patient's right.

Numbers to know

Item	Value
Probe	Phased array, 1–5 MHz
Typical depth	16–20 cm (parasternal ~16 cm)
RV basal diameter	>41 mm dilated;³ RV ≥ LV severe
IVC measurement point	1–2 cm from the RA junction³
CPR pulse-check scan	<10 s
Views in the outline	5 POCUS cardiac¹

Sources

1.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.org
2.Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease · ASE, 2013 · asecho.org
3.Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI · ASE/EACVI, 2015 · asecho.org
4.Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography · ASE, 2013 · asecho.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.