Cardiovascular OSCE Exam

Question 1

What are the 7 things you should do as part of your introduction?

Answer 1

Wash hands
Introduce yourself
Confirm patient details (name/DOB)
Explain the examination
Gain consent
Position patient at 45o with their chest exposed
Ask patient if they have any pain anywhere (before you begin)

Question 2

What should you look for at the bedside?

Answer 2

GTN spray
Oxygen
Mobility Aids
Medications

Question 3

On general inspection, what 5 things should you look for?

Answer 3

• Comfortable at rest?
• SOB at rest?
• Malar flush
• Scars / visible pulsations: look under the arms for thoracotomy scars / look for small scars from minimally invasive surgery
• Inspect the legs: scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes

Question 4

What is ‘malar flush’ and what might it indicate?

Answer 4

Plum red discolouration of cheeks.

Suggests Mitral Stenosis

Question 5

What are the 2 positions for hand inspection?

Answer 5

Hands out, palms facing downwards

Hands out, palms facing upwards

Question 6

What do you look for when patient has ‘hands out, palms facing downwards’?

Answer 6

• Splinter haemorrhages -> bacterial endocarditis

- Finger clubbing

Question 7

How do you test for finger clubbing?

Answer 7

• Ask the patient to place the nails of their index fingers back to back
• Healthy individual: observe a small diamond shaped window (Schamroth’s window)
• When finger clubbing is present this window is lost
• Finger clubbing has a number of causes including infective endocarditis and cyanotic congenital heart disease

Question 8

What 8(!) features do you look for when patient has ‘hands out, palms facing upwards’?

Answer 8

Colour – dusky bluish discolouration (cyanosis) suggests hypoxia

Temperature – cool peripheries may suggest poor cardiac output / hypovolaemia

Sweaty/clammy– can be associated with acute coronary syndrome

Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis

Osler’s nodes – tender red nodules on finger pulps / thenar eminence – infective endocarditis

Tar staining – smoker – risk factor for cardiovascular disease

Xanthomata – raised yellow lesions – often noted on tendons of wrist – caused by hyperlipidaemia

Capillary refill time – normal is <2 seconds – if prolonged may suggest hypovolaemia

Question 9

When assessing the radial pulse, what 2 features are you assessing?

Answer 9

Rate & Rhythm

Question 10

How would you identify a Radio-radial delay? What does this suggest?

Answer 10

Palpate both radial pulses simultaneously.
They should occur at the same time in a healthy adult.
Delay suggests Aortic Coarctation.

Question 11

How would you identify a ‘Collapsing pulse’. What does this suggest?

Answer 11

• Ensure the patient has no shoulder pain
• Palpate the radial pulse with your hand wrapped around the wrist
• Raise the arm above the head briskly
  Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation
• This is a water hammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g. AR / PDA) or high output states (e.g anaemia / AV fistula / thyrotoxicosis)
• Collapsing pulse = associated with Aortic Regurgitation

Question 12

When assessing the brachial pulse, what 2 features are you assessing?

Answer 12

Volume & character

Question 13

When measuring blood pressure, what should you consider?

Answer 13

Any abnormalities: Hypo / hypertension
Narrow pulse pressure -> ?Aortic stenosis
Wide pulse pressure -> ?Aortic regurgitation
* mention that you’d ideally measure BP in both arms

Question 14

What features of the Carotid pulse should you assess?

Answer 14

Character & volume
* slow, rising character in aortic stenosis
* It’s often advised to auscultate the carotid artery for a bruit before palpating, as theoretically palpation may dislodge a plaque which could lead to a stroke
However, if you perform carotid auscultation at this point, remember that the ‘bruit’ may actually be a radiating murmur!

Question 15

How would you assess / measure Jugular Venous Pressure (JVP)?

Answer 15

1. Ensure patient is positioned @ 45o.
2. Ask pt to turn their head away from you.
3. Observe neck for the JVP (located in line with the SCM)
4. Measure the JVP – number of cm from sternal angle to the upper border of pulsation

Question 16

What might raised JVP indicate?

Answer 16

Fluid overload
Right ventricular failure
Tricuspid regurgitation

Question 17

Explain how you’d carry out a Hepatojugular reflux assessment.

Answer 17

• Apply pressure to the liver
• Observe the JVP for a rise
• In healthy individuals this should last no longer than 1-2 cardiac cycles (it should then fall)
• If the rise in JVP is sustained and equal to or greater than 4cm this is a positive result

*This is very uncomfortable to perform correctly – an examiner will often prevent you performing it but remember to mention it!

Question 18

What does a positive Hepatojugular reflux sign suggest?

Answer 18

Right sided heart failure / Tricuspid regurgitation.

Question 19

What 3 features should you look for when assessing the eyes?

Answer 19

Conjunctival pallor – anaemia – ask patient to gently pull down lower eyelid

Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia

Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia

Question 20

What 4 features should you look for when assessing the mouth?

Answer 20

Central cyanosis – bluish discolouration of lips / underneath tongue

Angular stomatitis – inflammation of the corners of the mouth – iron deficiency

High arched palate – suggestive of Marfan syndrome – ↑ risk of aortic aneurysm/dissection

Dental hygiene – important if considering sources for infective endocarditis

Question 21

List 4 types of scars and what they might be indicative of.

Answer 21

Thoracotomy – minimally invasive valve surgery
Sternotomy – CABG / valve surgery
Clavicular – pacemaker (can be either side, so remember to check both)
Left mid-axillary line – subcutaneous implantable cardioverter defibrillator (ICD)

Question 22

What are the chest wall deformities you’d look for called?

Answer 22

pectus excavatum / pectus carinatum

Question 23

On finding a visible (forceful) apex beat, what might this suggest?

Answer 23

HTN / Ventricular hypertrophy

Question 24

Where & how would you find the apex beat?

Answer 24

5th Intercostal space, Mid-clavicular line

Palpate the apex beat with your fingers (placed horizontally across the chest)

Question 25

What does lateral displacement of the apex beat suggest?

Answer 25

Cardiomegaly

Question 26

What is a ‘parasternal heave’?

Answer 26

• A precordial impulse that can be palpated.

- Present in pts with Right ventricular hypertrophy.

Question 27

How would you identify a parasternal heave?

Answer 27

Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
If heaves are present, you should feel the heel of your hand being lifted with each systole.

Question 28

What is a ‘thrill’?

Answer 28

A palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur).

Question 29

How would you assess for a ‘thrill’?

Answer 29

• Assess for a thrill across each of the heart valves in turn.
• Place your hand horizontally across the chest wall, with the flats of your fingers & palm over the valve to be assessed.

Question 30

Describe how you’d auscultate the 4 valves.

Answer 30

Palpate the carotid pulse to determine the 1st heart sound.
Auscultate using the diaphragm of the stethoscope

Aortic valve – 2nd intercostal space – right sternal edge

Pulmonary valve – 2nd intercostal space – left sternal edge

Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge

Mitral valve – 5th intercostal space – midclavicular line (apex beat)

Repeat auscultation across the 4 valves with the bell of the stethoscope.

Question 31

How would you assess for radiation of a murmur?

Answer 31

1. Carotid arteries (with breath held): Radiation of aortic stenosis murmur.
2. Axilla: Radiation of heart murmur into left axilla -> mitral regurgitation
3. Left sternal edge: Aortic regurgitation

Question 32

Explain the principles behind Accentuation manoeuvres.

Answer 32

• Manoeuvres cause particular murmurs to become louder during expiration.
• Roll onto left side & listen to mitral area with bell during expiration - mitral murmurs (stenosis & regurgitation)
• Lean forward & listen over aortic area during expiration - aortic murmurs are louder (stenosis & regurgitation)

Question 33

Describe the routine you might use for the accentuation manoeuvres

Answer 33

Start from mitral area

Listen ‘upwards’ through the valve areas using the diaphragm of the stethoscope (mitral -> tricuspid -> pulmonary -> aortic) using appropriate breathing manoeuvres

Repeat the process using the bell of the stethoscope
Continue upwards to the carotids (check for aortic stenosis radiation)

Sit forwards (check for aortic regurgitation radiation)
Roll onto to the left (check for mitral regurgitation)

Question 34

What might you hear on auscultation of the lung bases?

Answer 34

Crackles -> Pul. oedema (eg. secondary to Left ventricular failure).

Consider chronic lung diseases if the patient has no other signs of fluid overload (e.g. pul. fibrosis).

Question 35

What are the 2 types of oedema which can indicate Right ventricular failure?

Answer 35

Sacral & pedal

Question 36

What are the final 3 things you must do to finish the examination?

Answer 36

Thank patient
Wash hands
Summarise findings

Question 37

What further investigations might be suggested?

Answer 37

• Full peripheral vascular examination
• 12 lead ECG - arrhythmias / Myocardial ischaemia
• Dipstick urine - proteinuria / haematuria -? HTN
• Bedside capillary blood glucose -?Diabetes
• Fundoscopy - malignant HTN -? Papilloedema