CARDIO EXAM P/F YEAR Study Hub OSCE Sessions Lizkerry Odeh Outline ■ Introduction – explanation, consent, chaperone ■ General bedside inspection: environment ■ General bedside inspection: patient ■ IPPA ■ Conclusion ■ Summarise + next steps What to be aware of during the Cardio Exam ■ MUMURS Aortic stenosis, mitral regurgitation, less commonly: heart defects, mitral stenosis, aortic regurgitation TIP: a new murmur should be treated with precaution – it could mean IE or an MI ■ HEART FAILURE Fluid overloaded, may hear fluid in the lungs, may also be signs of the cause eg post MI ■ INFECTIVE ENDOCARDITIS New murmur, fever, peripheral signs – MAJOR VS MINOR CRITERIA IPPA ■ I – inspection ■ P – palpation ■ P – percussion ■ A – auscultation ■ Tip: IPPA is the basic format of most clinical examinations – except from MSK Introduction ■ Introduce yourself and confirm patients name + DOB ■ WASH YOUR HANDS ■ Explain examination before gaining consent – exposure ‘undressed from the waist up’, chaperone, for your learning, brief description of CVS exam ■ “Are you happy to begin” ■ Double check if the patient is in any pain – can I get you any pain relief? ■ BEDSIDE INSPECTION: ECG/cardiac monitor, medication, IVs, oxygen ■ PATIENT INSPECTION: cyanotic, breathless, pain, fluid overloaded? Closer Inspection ■ Inspect from the hands, work your way up to the arms, then the neck, then the face and then the chest - HANDS: splinter hemorrhages, janeway lesions, osler nodes, cap refill - ARMS: offer BP, radial pulse (character eg slow rising vs bounding rate, rhythm) radial radial delay, collapsing pulse – check shoulder pain! What does radial radial delay and collapsing pulse show? - NECK: JVP at 45 degrees, carotid pulse (auscultate before palpation) and describe character and volume, are there carotid bruits – carotid bruits indicate? What should be done if carotid bruits are heard? What are the causes of a raised JVP? - FACE: conjunctivial pallor, malar flush, xanthelasma, corneal arcus. What is malar flush a sign of? - CHEST: scars, deformities, heaving apex beat o TIP: ensure you are having a PROPER look, eg lift the arm up, get close to the patient. Also try to relate the clinical signs to the underlying pathology/disease Palpation ■ Heaves LV hypertrophy ■ Thrills Palpable murmur ■ Apex beat Displaced? Tapping? Unable to palpate? Auscultation ■ Listen over 4 valve areas ■ Ask patient to breathe in and hold – helps you hear the heart sounds better ■ PALPATE RADIAL PULSE SIMULTAENOUSLY, helps distinguish between S1 + S2 ■ Describe what you can hear: - HI + HII + 0 is normal - Extra sounds: S3, S4, clicks, snapping - Murmurs: ejection systolic, diastolic – early vs late, pan systolic – if you hear ejection systolic, always check if it radiates to carotids! o Murmur manouvre: Aortic Regurgitation and Mitral Stenosis o Auscultate lung bases – fluid overloaded? Murmurs ■ If you hear a murmur, you need to be able to describe it accurately!! • Location • What part of the cardiac cycle? Systolic vs diastolic • Did it radiate – ejection systolic: check for carotid radiation, pan systolic check for axilla radiation • Louder on inspiration or expiration? RILE – right sided murmurs are loudest on inspiration, left sided on expiration § TIP: you can suggest what the murmur is consistent with. Eg “On auscultation HI + HII sounds were present but I was also able to hear an ejection systolic murmur, loudest over the aortic region which radiated to the carotids. This is consistent with Aortic Stenosis however an ECHO would be required to confirm” BUT only mention this if you are comfortable with your findings! Closure ■ Check: pitting odema, swollen legs ■ How to close: - Thank the patient – any help getting dressed, any questions? - Summarise briefly including important positives and negatives - Further investigations: BEDSIDE: respiratory, peripheral vascular, ECG, pulse oximetry BLOODS: FBC, troponin, BNP, clotting IMAGING: CXR, ECHO if indicated Closure (example) ■ “Today I saw Mr T, a 72 year old man who presented with SOB. On inspection from the bedside there was no stigmata of cardiovascular disease of both the environment and of the patient. On closer inspection, this was also true. Heart rate was 68 bpm, regular pulse and normal character. There were no heaves or thrills on palpation and heart sounds were normal with no murmurs or added sounds. Lungs were clear with signs suggestive of pulmonary edema. There were also no signs of peripheral odema.” ■ “In conclusion, this were no positive findings consistent with cardiovascular disease. To further my examination I would like to..” ■ TIPS: say what is important! The examiner doesn’t REALLY need to know about splinter hemorrhages but they do need to know if the heart rate was irregular or if there were added heart sounds. Reminders o Take your time but beware of the time! o Be thorough! o Stay communicating with the patient! o Be honest! If you can’t hear or feel something, say so. FEEDBACK? THANK YOU!.