Cardiac OSCE

Question 1

What is pulsus alternans?

Answer 1

alternating strong and weak pulse palpable at radial or femoral arteries

Question 2

What causes a water hammer pulse?

Answer 2

Due to large stroke volume and backflow of blood from the aorta into LV

*indicative of aortic regurgitation.

Question 3

What can a paradoxical pulse be used for?

Answer 3

to assess pericarditis or tamponade when there is varied pulse strength/amplitude with respiration

Question 4

What is Kussmaul’s sign?

Answer 4

• 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 5

When might you see a hyperkinetic high amp impulse?

Answer 5

• hyperthyroidism
• severe anemia
• pressure overload of LV from HTN or aortic stenosis
• volume overload of LV from AR

Question 6

Aortic Stenosis

Answer 6

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

Question 7

Mitral Regurgitation

Answer 7

• Blowing quality, holosystolic
• Prominent at apex, radiates to LEFT axilla
• Loudness correlates with degree of valve insufficiency

Question 8

Pulmonary Stenosis

Answer 8

• Harsh, loud, ejection click
• LEFT 2nd ICS/3rd ICS
• Radiates to the LEFT shoulder
• Increases with inspiration

Question 9

Tricuspid Insufficiency

Answer 9

• Blowing quality, increases with inspiration
• Holosystolic
• Lower LEFT sternal border

Question 10

Aortic Regurgitation

Answer 10

• Blowing, decrescendo murmur
• LEFT 2nd ICS to the 4th ICS
• Auscultate with diaphragm

Question 11

Mitral Stenosis

Answer 11

• Rumbling, low pitched
• Best heard at apex
• Auscultate with bell

Question 12

Pulmonary Insufficiency

Answer 12

• Blowing quality

Question 13

Tricuspid Stenosis

Answer 13

• Increases in intensity with inspiration

- Decreases in intensity with expiration and valsalva

Question 14

What are the following special tests used for?

1. Left lateral decubitus
2. Sitting and leaning forward
3. Straining/valsalva
4. JVP

Answer 14

1. 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
2. Increases chance of hearing aortic regurgitation
3. Increases chance of hearing mitral regurgitation
4. Hepatojugular reflex

Question 15

What does valsavla help with?

Answer 15

differentiate between aortic and mitral prolapse or HCM

Question 16

What is hepatojulular reflex used for?

Answer 16

adjunct to measuring JVP

Question 17

How can you differentiate between aortic stenosis and MVP?

Answer 17

sitting and squatting test