2. Cardio osce

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Cardio OSCE

Examination

9) Further investigations

8) Reverse WIPE: - Wash your filthy hands. - Thank the patient. - AND FOR THE LOVE OF GOD MAN, GIVE THE PATIENT HIS DAMN SHIRT BACK - Summarize findings.

7) Chest: - Look - Feel - Listen

Auscultation: Remember to auscultate while feeling pulse!

Offer to listen to lung sounds for Bi-basal creps.

Radiations

Additional HS: i. Opening snap: (Occurs post S2; Mitral stenosis) ii. Mid systolic click (MVP) iii. S3 = FUCK...you're screwed (Ventricular dilatation) iv. S4 = well FUCK...you (Ventricular hypertrophy)

S2 = End of systole - PV, AV - Loud S2 = HTN - Soft S2 = Heart block - Ask pt to INHALE DEEPLY to split S2 (A2 --> P2). Best appreciated over PV i. Pulmonary stenosis ii. VSD iiii. R BBB

S1 = Start of systole - MV, TV - Soft S1 = Heart block

Palpation: - Apex beat (displaced?) - Heaves - Thrills

Thrills = Palpable mumurs @ AV, PV

Heaves = RV enlargement

Apex beat

General observation: - Scars? - Pacemaker? - Visible apex beat?

EXPOSE THE PATIENT

6) Neck - raised JVP

5) Face

Mouth

Peripheral cyanosis Central cyanosis Dental caries Marfan's high arched palate Fetor hepaticus

Cheeks

Malar flush

Eyes

Conjunctival icterus Conjunctival pallor Xanthelasmata

4) Offer to take BP

Sounds

How-to

4) Arms No spider naevi

3) Hands

Pulse: - Rate - Rhythm - Character - Delay

Delay: i. Radio-radial : Large art occln ii. Radial-femoral : Aortic coarctation

Character: - Bounding (CO2 retention; HOCM) - Collapsing pulse (aortic regurg) - Slow rising (aortic stenosis)

Should you run out of things to say, mention cardiogenic liver failure (i.e. per RHF): Leukonycia Koilnonychia

Temperature Nicotine staining Cyanosis Cap refill Splinter haemorrhages Janeway lesions/Osler nodes Palmar crease pallor

2) General observation

Surroundings

Oxygen? Walking aids? IV? Fluid restriction? Sputum mug? Call button? End of beds?

Patient

Distress? Cachetic? Edematous? SoB? Marfan's? (Tall w. kyphosis) Down's? TED socks? Cath'ed?

1) WIPE - Ask about pain/discomfort!!! - Pt to be seated at 45 degrees - Place, person, time!!!

History taking

Thank the pt Clean your hands Summarize findings

ICE

RoS

If not mentioned in PMH, ask about: - DM - CKD - ED

Social Hx

SAD Life S moking A lcohol D iet Lifestyle: - Job? - Exercise?

F Hx

Hx of CVD/CHD Hx of sudden death

Drug hx

i.e. B antagonists (asthma); thyroxine Meds for the limp dick (slidnafil potentially fatal when combined with anti-HTN meds) - Fun fact: You literally die with a raging boner, and as they say...'Rage; Rage against the dying of the light.'

PMH

Hx of HD (include RHF + IE) Hyperlipidemia HTN PVD Prosthetics DM CKD The limp dick CONGENITAL HD & MYOPATHIES

Cardinal symptoms

Intermittent claudication

Then Durp the derp: D istance before onset? U phill walking? R esting claudication (severe occlusion) P lace of pain (i.e. anatomical location)

MUST ASK ABOUT THE 6 P's of PVD: P ain P allor P ulselessness P aresthesia P aralysis P erishingly cold

Fatigue

Determine per exercise tolerance. Is fatigue caused by: - SoB? - Angina? (Canadian cardiac score) - or claudication?

Arrhythmias

Establish chronology: - Onset, timing Tap out HR. Associated dizziness?

Syncope

Duration Onset Triggers Associations

Edema Proximal progression

Do you have difficulties putting on your shoes? Increase in weight? (per fluid retention) When is the swelling worst? (typically worse at the end of the day, and better in morning as edema is redistributed systematically)

Chest pain

SOB MMRC score!!!

Questions to ask: Is cough productive? (pink, frothy sputum if cardiogenic) Is breathing noticeable? (i.e. chronic +++ work of breathing) Is dyspnoea CARDIOgenic or PULMOgenic? - Cardiogenic SoB = 70% association w/ PND and orthopnea