CARDIOVASCULAR EXAM/HISTORY Study Hub OSCE Sessions Dr Alison Cheung Structure
■ Cardiovascular examination
■ OSCE tips
■ Cardiovascular history
■ Communication skills CARDIOVASCULAR EXAM Cardio exam - Introduction
■ WIPP – Wash hands – Introduce yourself (Name and position) – Identity: Confirm the patient’s name and DOB – Permission: – State that you would like to perform an exam – Explain what the exam will involve – Exposure, chaperone – Ask if they have any questions and if they are ok to begin – Position: Position patient 45’ in bed, ask if the patient has any pain
IPPA - Inspection, Palpation, Percussion, Auscultation Cardio exam - Inspection
■ Bedside inspection ■ Closer inspection of the – Oxygen, fluids, medication, ECG, patient cardiac monitor, GTN spray – Hands – Nails – Wrist ■ General inspection of the patient – Arm – General appearance - well or unwell, in pain, distressed, cyanotic, breathless, fluid overloaded Cardio exam – Hand + Nails
■ Perfusion: – temperature – peripheral cyanosis – cap refill (>2 seconds in hypoperfusion) ■ Nails: – Clubbing (IE, cyanotic congenital heart disease) – Splinter hemorrhages (IE) – Koilonychia (iron deficiency anaemia) ■ Dorsum of hand: – Extensor tendon xanthomata (hyperlipidaemia) ■ Palm: – Osler’s nodes (IE, rheumatic fever) – Janeway lesions (IE, rheumatic fever) Cardio exam - Arms
■ Inspection: – Bruising (anticoagulation) – scar (radial artery harvest for CABG) ■ Radial pulse – rate (N =60-100bpm) – rhythm (regular, regularly irregular or irregularly irregular) – volume (normal, thready, bounding) – radio-radial delay (assess over 10 secs; aortic coarctation, aortic dissection, embolism, cervical rib) – offer to test radio-femoral delay (aortic coarctation, aortic dissection) ■ Collapsing pulse – Shoulder hurt? – Occlude radial pulse + feel for brachial pulse, raise arm above head – If brachial pulse disappear after raising hand = collapsing pulse (Aortic regurgitation) ■ Mention you would now measure the BP (measure in both arms if radio-radial delay) Cardio exam – Closer inspection of patient
– Face ■ Malar flush (mitral stenosis)
– Eyes ■ Corneal arcus and xanthelasma (hypercholesterolaemia) ■ Conjunctival pallor (anaemia)
– Mouth ■ Central cyanosis (lung disease, cardiac shunt, hypoxia) ■ Poor dentition (risk of IE) ■ Tongue cracked? (hydration) Cardio exam - Neck
■ Inspection – De Musset’s sign – Head bobbing to heartbeat = severe aortic regurgitation
■ JVP (Jugular venous pressure) – Head turned slightly to the side – Seen up to 3 cm above sternal angle, between the two SCM heads ■ You shouldn’t see it - >3cm = heart failure, fluid overload, pulmonary HTN – Push RUQ – temporary increase of JVP (hepatojugular reflux)
■ Carotid pulse – Auscultate for bruits ■ Use bell – “breathe in and hold your breath” ■ Palpate radial pulse at the same time – Palpate: character and volume ■ 1 side @ a time! Cardio exam - Chest
■ Inspection – Scars (median
– Thrills (palpable murmur) ■ Place the base of your fingers on patient’s at all four heart valve positions ■ = turbulent blood flow ■ AS thrill most common (pulmonary area) – pulmonary HTN Cardio exam – Auscultation of chest
■ Auscultate – Listen over all 4 heart valves and simultaneously palpate the radial pulse – If you hear a murmur - where is it the loudest, timing, character, volume and radiation ■ Mitral valve - palpate apex beat, then auscultate ■ To confirm MM – roll patient to left, listen to left axilla with bell ■ Tricuspid valve ■ Pulmonary valve ■ Aortic valve ■ Listen over carotid artery and get the patient to hold their breath (aortic stenosis – § Pulmonary oedema carotid bruits) – Auscultate lungs ?fine ■ Ask the patient to lean forward and breath crepitations out (aortic regurgitation) – HI + HII + 0 is normal ■ Peripheral oedema – Extra sounds: S3, S4, clicks, snapping – Palpate tibia / medial – Murmurs = RILE (right on inspiration, left on malleolus for 10 seconds expiration) ?pitting Cardio exam - End and to complete
■ Thank patient ■ Offer to help patient get dressed ■ Does the patient have any questions? ■ Summarise findings and suggest differential diagnosis and/or further investigations – Bedside: Respiratory exam, Peripheral vascular exam, other baseline observations (Sats, Temperature) ECG, ABG – Bloods: FBCs, U&Es, LFTs, Troponin, BNP, Clotting profile – Imaging: CXR, ECHO
*Only mention those investigations that are relevant OSCE TIPS OSCE tips
■ Approach with confidence – know what you’re looking for ■ Explain what you are doing to patients ■ Running commentary “I’ll be explaining my findings to the examiner as I go along” ■ If stuck – “I’ll take a moment to gather my thoughts” ■ Practice Practice Practice CARDIOVASCULAR HISTORY Cardiovascular history - Introduction
■ Name, role ■ Confirm patient’s name and DOB ■ Why you’re speaking to them ■ Confidentiality ■ Consent Cardio history – Presenting complaint
■ Pain – SOCRATES ■ Syncope – before, during, after ■ Site, onset, character, radiation, associated – Aortic stenosis – SOB + chest pain symptoms, timing (constant/intermittent), + syncope exacerbating and relieving factors, severity – Arrythmia (random +/- palpitations) (0-10) – Postural hypotension (after ■ Radiate to left arm and neck/jaw (ACS) standing quickly) ■ Crushing central chest pain, nausea, sweaty/clammy (myocardial infarction) ■ Relieved when lean forward (pericarditis) ■ SOB ■ Radiates to the back (aortic dissection) – Onset, exacerbating factors, ■ Last for few mins +/- brought on by normal vs current exercise exertion and relieved by rest (angina) tolerance ■ Palpitations – More pillows? Paroxysmal – Regular / irregular (tap out rhythm); fast/slow? nocturnal dyspnea (HF) – Associated – nausea, LOC, – Cough? Sputum (colour, blood, sweating/clamminess, SOB amount)? Wheeze? – Episodic? How does it feel like? What brings it – Leg swelling (HF) on? Cardiovascular history
Other differentials for chest pain: ■ Respiratory – Pleuritic chest pain – PE ■ Gastrointestinal – Epigastric pain – Acid reflux / heartburn ■ MSK cause – Tenderness on specific point on palpation – costochondritis / rib # ■ Psychological cause – Anxiety Cardiovascular history
■ History of presenting complaint – Previous episode? – Systems review: Head to toe – Red flag symptoms: Fever, clammy/sweaty, chest pain ■ Past medical/surgical history – Diabetes, hypertension, high cholesterol – Been to the hospital for anything? See the GP regularly for anything? ■ Drug history (+OTC and herbal) and allergies (what happens?) ■ Family history ■ Heart problems / lung problems – Sudden death, diabetes, hypertension ■ Social history – Living circumstances, Job, Impact on life, Smoking (do you smoke? Have you ever smoked? How many/day? How long have you smoked?) Recreational drugs, Alcohol (how much per week?), diet ■ ICE - ideas, concerns, expectations ■ End – thanks, questions, safety net Summary of history - example
■ Today I’ve spoken to Mrs Smith, who is a 64 year old lady presenting with sudden onset chest pain. ■ She described it as a central crushing pain, radiating to her neck and left arm, associating with clamminess, SOB and nausea. She has no vomiting, no fever or LOC. ■ She has had this pain before, which is usually brought on by exertion and relieved by rest, lasting a few minutes. ■ Her past medical history includes T2 diabetes and hypertension. She takes metformin and amlodipine regularly and has no drug allergies. ■ She is an ex smoker, stopped 3 years ago. She does not drink alcohol or use recreational drugs. ■ In summary this is a 64 year old lady with sudden onset central chest pain. ■ My top differentials include myocardial infarction and unstable angina. ■ I would like to perform a cardio-respiratory examination, obtain baseline observations (temperature, saturations, HR), perform an ECG and get some blood tests including FBC, troponin, U&Es. ■ I would like a senior review. COMMUNICATION SKILLS Communication skills
■ Start with open questions, let the patient talk ■ Active listening, empathy ■ Chunk and check, summarise back ■ Signpost ■ Go with patients’ agenda ■ Thought parking ■ Form differentials in your head as you go along ■ Structure structure structure ■ ICE ICE ICE – early! FEEDBACK? THANK YOU!