Makindo Medical Notes.com

Examination is an active process and one must be thinking and looking for things not expecting them to just jump out at you.

Cardiac exam: Overall plan

Wash hands, Introductions, consent End of bed: Inspect head to toe and environment Look at hands, pulse and ask BP Look at neck - JVP : Hepatojugular reflex Look at chest - scars, pulsations, deformity, pacemaker Palpate apex beat, examine for thrills Auscultate 6 areas: apex, axilla, LSE, aortic, pulmonary areas, carotids Listen to lung bases and note any pre sacral oedema Look at legs - vein striped for CABG and oedema Thank patient, wash hands, present findings

Cardiology Examination OSCE

Introduction (Use the acronym WIPER to prepare for the examination)

• W - Wash your hands
• I - Introduce yourself and confirm patient details
• P - Permission - gain consent to proceed with the examination, including explaining relevant details
• E - Expose the patient appropriately, gather Equipment
• R - Position the patient lying back at 45 degrees comfortably

Inspection

• Appearance
  • Breathless at rest : Anaemic | Plethoric |Thin | Obese
  • Paraphernalia by the bed: ECG telemetry | GTN spray |Oxygen mask or nasal | IV infusions | Pacemaker lead and box
  • Scars: Midline thoracotomy: CABG | Valve replacement |Correction of congenital heart disease
  • Pacemaker and scar usually left or right infraclavicular

Face

• Lips/Mucosa : Central cyanosis : over 5g/dl of deoxygenated Hb
• Mouth
  • Central cyanosis (> 5 g/dl of deoxygenated Hb)
  • Dentition (risk of valve infections)
• Eyes
  • Xanthelasma/Corneal arcus: hypercholesterolaemia
  • Anaemia
• Dentition - potential source of sepsis if rotten (one does not need a dental degree to have a look and comment)
• Mitral facies (malar flush) - suggests Mitral stenosis
• Inherited Syndromes
  • Down's syndrome - AV canal defects (ASD/VSD)
  • Turner's syndrome - Coarctation of Aorta and Bicuspid Aortic valve
  • Marfan's syndrome : look in mouth for high arched palate
• Other appearances with cardiac issues
  • Thyrotoxic: AF, signs of Grave's disease with eye and skin signs or a goitre
  • Acromegalic: Hypertension and cardiomegaly

Hands

• Clubbing (infective endocarditis, cyanotic heart disease, atrial myxoma)
• Warm, dilated veins suggest normality or possibly CO₂ retention.
• Cold hands: poor cardiac output or peripheral vascular disease.
• Nicotine staining in a smoker
• Clubbing is an important sign
  • Cyanotic congenital heart disease in a young person
  • Infective endocarditis
  • Left atrial myxoma
• Signs of Endocarditis in Hands
  • Splinter haemorrhages - can be a sign of nail trauma in a manual worker or endocarditis. Traumatic lesions are usually seen mainly in the dominant hand. Ask about work done if suspicious
  • Osler's nodes - painful lesions in finger pulp suggests endocarditis
  • Janeway lesions - Erythematous lesions on palm suggest endocarditis
• Nail fold telangiectasia in those with collagen vascular disease.
• Arachnodactyly "spider fingers" and high arched palate: Marfan's syndrome
• Elasticated skin and joint flexibility: Ehlers-Danlos (Aortic regurgitation)
• Elbow: Tendon xanthomata suggests hypercholesterolaemia

Radial pulse (if difficult consider brachial or carotid)

• Rate: measure 15 seconds and x 4
  • Rate > 100: tachycardia and Rate < 60 : Bradycardia
  • In fast AF the pulse may not reflect true heart rate (Pulse deficit)
• Rhythm
  • Irregular irregular: Atrial fibrillation | Normal rhythm with multiple ectopics
  • Regularly Irregular: Heart blocks or ectopics
• Character of the pulse
  • Slow rising (Aortic stenosis)
  • Jerky (Hypertrophic cardiomyopathy
  • Thready: Shock
  • Bounding: High output e.g. post exercise, thyrotoxicosis, fever, Hyperdynamic circulation, severe Paget's disease
  • Collapsing pulse: Aortic regurgitation or AV fistula. Low diastolic pressure. Wide pulse pressure.
  • Plateau pulse: Slow rising small "pulsus parvus" seen with Aortic stenosis. Narrow pulse pressure.
  • Pulsus Bisferiens: Mixed collapsing and plateau pulse with mixed aortic valve disease
  • Pulsus alternans: Alternating large and small beats and suggests severe LV dysfunction
  • Pulsus bigeminus: caused by a premature beat before every QRS complex
  • Pulsus paradoxus: BP fall with inspiration is exaggerated > 10 mmHg. Pulse weakens with inspiration
    • Cardiac Tamponade
    • Pericardial constriction
    • Acute severe asthma
  • Absent Pulse
    • Dissection of aorta with ipsilateral subclavian involved
    • Arterial thrombosis or embolism in subclavian or brachial or may be seen post catheterisation (angiography now done via radial artery)
    • Takayasu's disease
    • Very low volume pulse
• Examine for Radial–Femoral delay in Coarctation of the aorta
• Raise hand and feel for tapping over the pulse - Aortic incompetence

Ask for the blood pressure

• BP > 140/90 Hypertension
• Narrow pulse pressure : aortic stenosis
• Wide pulse pressure: aortic incompetence

Neck

• Jugular venous pressure (raised >4 cm)
• Palpate carotid pulse (character)

Listening to murmurs -Traditionally these are the areas but do not really take into account different chest anatomy and physiology and jets of turbulence can be heard outside these areas. Instead of these 4 areas, one can just start in the apex and slide the stethoscope across to the tricuspid area, up the LSE to the pulmonary area and over into the aortic areas listening as you go. A sort of sigmoidal shape. Remember to have one finger on a pulse at all times.

Praecordium

• Inspect
  • Have a second look for scars, pulsations, swellings, pacemaker
  • Other findings : pectus excavatum, Gynaecomastia (Spironolactone)
• Palpates apex beat which should be in 5th ICS MCL or displaced towards axilla
• Palpate sternal edges and sub clavicular areas for thrills
• Auscultates chest:
  • Mitral area/apex beat (5th intercostal space[ICS], midclavicular line)
  • Tricuspid area (4th ICS, right sternal edge)
  • Pulmonary area (2nd ICS, right sternal edge)
  • Aortic area (2nd ICS, left sternal edge)
  • Palpate radial artery simultaneously to time murmur
  • Cardiac manoeuvres:
    • Auscultates mitral area with patient lying on left side and in expiration for murmur of mitral stenosis
    • Auscultates aortic area with patient sitting forward and in expiration for murmur of aortic regurgitation
  • Auscultates lung bases for pulmonary oedema
  • Palpates shins or ankles for peripheral oedema

Finishing

• Thank patient and offers to help patient get dressed
• Wash hands and think about how to present your findings
• Present Findings and suggest a differential diagnosis
• Suggests appropriate investigations and management