Cardiac OSCE

Question 1

What is the pulse grading scale?

Answer 1

0	Absent, Not Palpable
1	Diminished, barely palpable
2	Expected
3	Full, increased
4	Bounding

Question 2

what does a normal carotid feel like?

Answer 2

● Normal carotid: Feels like sharp knock; abnormal is a weak nudge then slight pulsation or push

Question 3

What is a water-hammer pulse?

Answer 3

● Water-hammer pulse: Due to large stroke volume and backflow of blood from the aorta into LV; indicative of aortic regurgitation.
o Palpate radial pulse while the patient lies on the exam table, applying pressure until pulse is obscured. Raise arm straight over patient’s head, perpendicular to the table, and palpate pulse for a sudden rise and collapse of radial pulse that feels “jumpy”

Question 4

What is a pulsus alternans?

Answer 4

● Pulsus alternans: Alternating strong and weak pulses palpable at radial or femoral arteries

Question 5

what is a paradoxical pulse?

Answer 5

● Paradoxical pulse: can be used to assess pericarditis or tamponade when there is varied pulse strength and amplitude as patient breathes

Question 6

what is Kussmaul’s sign?

Answer 6

● Kussmaul’s sign: Normal JVP shows decline in inspiration but the a wave amplitude increases. If there is an increase in JVP, or even no change in JVP on inspiration, this is a positive Kussmaul’s and may indicate impaired venous return to the right heart.

Question 7

In the left lateral decubitus position, a diffuse PMI with a diameter >___cm signals left ventricular enlargement; a diameter of >__cm makes left ventricular overload almost 5 times more likely.

Answer 7

In the left lateral decubitus position, a diffuse PMI with a diameter >3cm signals left ventricular enlargement; a diameter of >4cm makes left ventricular overload almost 5 times more likely.

Question 8

A hyperkinetic high-amplitude impulse may occur in what conditions?

Answer 8

A hyperkinetic high-amplitude impulse may occur in hyperthyroidism, severe anemia, pressure overload of the left ventricle from hypertension or aortic stenosis, or volume overload of the left ventricle from aortic regurgitation.

Question 9

What is the murmur grading scale?

Answer 9

1/6 Very faint; not heard in all positions No
2/6 Soft, but heard immediately after placing stethoscope on chest No
3/6 Moderately loud No
4/6 Loud, with palpable thrill Yes
5/6 Very loud, with thrill. May be heard with stethoscope partly off chest Yes
6/6 Very loud, with thrill. May be heard with stethoscope entirely off chest Yes

Question 10

What are the four Common SYSTOLIC Murmurs?

Answer 10

Common SYSTOLIC Murmurs:
● Aortic Stenosis

● Mitral Regurgitation

● Pulmonary Stenosis

● Tricuspid Insufficiency

Question 11

What are the four Common DIASTOLIC Murmurs?

Answer 11

Common DIASTOLIC Murmurs:
● Aortic Regurgitation

● Mitral Stenosis

● Pulmonary Insufficiency

● Tricuspid Stenosis

Question 12

aortic stenosis

Answer 12

● Aortic Stenosis
○ Harsh quality
○ RIGHT 2nd ICS/3rd ICS
○ Radiates to suprasternal notch and carotids
○ Delayed pulses (pulsus tardus et parvus)

Question 13

mitral regurgitation

Answer 13

● Mitral Regurgitation
○ Blowing quality, holosystolic
○ Prominent at apex, radiates to LEFT axilla
○ Loudness correlates with degree of valve insufficiency

Question 14

pulmonary stenosis

Answer 14

●	Pulmonary Stenosis 
○	Harsh, loud, ejection click 
○	LEFT 2nd ICS/3rd ICS
○	Radiates to the LEFT shoulder
○	Increases with inspiration

Question 15

tricuspid insufficiency

Answer 15

● Tricuspid Insufficiency
○ Blowing quality, increases with inspiration
○ Holosystolic
○ Lower LEFT sternal border

Question 16

aortic regurg

Answer 16

● Aortic Regurgitation
○ Blowing, decrescendo murmur
○ LEFT 2nd ICS to the 4th ICS
○ Auscultate with diaphragm

Question 17

mitral stenosis

Answer 17

● Mitral Stenosis
○ Rumbling, low pitched
○ Best heard at apex
○ Auscultate with bell

Question 18

pulmonary insufficiency

Answer 18

● Pulmonary Insufficiency

○ Blowing quality

Question 19

tricuspid stenosis

Answer 19

● Tricuspid Stenosis
○ Increases in intensity with inspiration
○ Decreases in intensity with expiration and valsalva

Question 20

what is the purpose of having a patient lay left lateral decubitus?

Answer 20

Left lateral decubitus
● Patient on left side with left arm above head
● Palpate PMI and auscultate for systolic murmurs
● Increases chance of hearing mitral stenosis and extra heart sounds

Question 21

what is the purpose of having a patient sit and lean forward?

Answer 21

Sitting and leaning forward

● Increases chance of hearing aortic regurgitation

Question 22

what is the purpose of having a patient strain/do valsava?

Answer 22

Straining/Valsalva

● Increases chance of hearing mitral regurgitation

Question 23

Valsalva maneuvers ______ murmur duration in MVP

Valsalva maneuvers ______ murmur intensity for HCM

Answer 23

● Valsalva: used to differentiate between aortic and mitral prolapse or hypertrophic cardiomyopathy
o Valsalva maneuvers increase murmur duration in MVP
o Valsalva maneuvers increase murmur intensity for HCM

Question 24

How to differentiate between aortic stenosis and mitral valve prolapse or hypertrophic cardiomyopathy?

Answer 24

● Sitting and Squatting: Used to differentiate between aortic stenosis and mitral valve prolapse or hypertrophic cardiomyopathy
o Have patient stand then squat.
▪ Squatting increases venous return, peripheral vascular resistance, stroke volume, and blood pressure, while standing has opposing effects.
o Auscultate during the squatting and standing phases.
▪ During the squatting, a MV prolapse and HCM will give delay in click and decrease in murmur intensity.

Question 25

when is the abdominal jugular reflex positive?

Answer 25

o Test is positive when there is a sustained increase in JVP by > 4 cm within 3-5 sec after pressure removed.

Question 26

An elevated JVP in highly correlated with what?

Answer 26

An elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis.

Question 27

What does JVP look like in patients with obstructive lung disease?

Answer 27

In patients with obstructive lung disease, JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure.