OSCE Flashcards
What do you look for in the general inspection for the CVS exam?
General health Respiratory distress Shortness of breath Pallor Oedema Cyanosis Cachexia Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis
Treatments or adjuncts? – GTN spray / O2 / medication / mobility aids
Inspect chest – scars or visible pulsations?
Inspect legs – scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes
What do you look for in the peripheries for CVS?
Hands and wrists:
Palm down:
Finger clubbing (cyanotic heart disease or endocarditis)
Splinter haemorrhages (trauma or invective endocarditis)
Capillary refill time
Palm down:
1) Cyanosis
2) Temperature
3) Sweaty (acute coronary syndrome)
4) Janeway lesions - (non-tender maculopapular erythematious palm pulp lesions (bacterial endocarditis)
5) Osler’s nodes – tender red nodules on finger pulps/thenar eminence – infective endocarditis
6) Pallor of the palmar creases (anaemia)
7) Tar-staining
8) Tendon xanthomata - (yellow/orange lipid deposits on the tendons of the hand (hyperlipidaemia)
What do you look for in the face in CVS?
Open or closed mouth breathing
Any pain
Sweating (cardiac pain or infection)
Skin colour or rash
Eyes: Conjuntival pallor (anaemia) Corneal arcus (yellowish ring surrounding the iris - hypercholesterolaemia). Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia
Mouth:
Central cyanosis
Angular stomatitis - inflammation of the corners of the mouth - iron deficiency
High arched palate - Marfan syndrome (increased risk of aortic aneurysm)
Dental hygiene - causes of invective endocarditis.
What do you look for in the chest inspection in CVS?
Scars:
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)
Chest wall deformities – pectus excavatum / pectus carinatum
Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy
What do you look for in palpation of the heart?
Apex beat - use palm and then index finger. Note if it is normal or forceful (left ventricular hypertrophy). Note the position of the beat.
Parasternal heave - (right ventricular hypertrophy) - palm of the hand to the left sternal edge
Thrills - vibration caused by turbulent blood flow through a heart valve
Where do you assess with cardiovascular auscultation?
Mitral valve – 5th intercostal space – midclavicular line (apex beat)
Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge
Pulmonary valve – 2nd intercostal space – left sternal edge
Aortic valve – 2nd intercostal space – right sternal edge
Also use the bell on the apex beat.
Auscultate the carotid arteries with the patient holding their breath to check for radiation of an aortic stenosis murmur (this is known as an accentuation manoeuvre).
Sit the patient forwards and auscultate over the aortic area during expiration to listen for the murmur of aortic regurgitation (this is known as an accentuation manoeuvre).
Roll the patient onto their left side and listen over the mitral area with the bell during expiration for mitral murmurs (regurgitation/stenosis).
What do you look for in general observations of the respiratory system?
Does patient look short of breath? – nasal flaring / pursed lips / use of accessory muscles / intercostal muscle recession
Is the patient able to speak in full sentences?
Respiratory rate
Cyanosis
Surgical scars
Sputum
Chest wall – note any abnormalities or asymmetry – e.g. barrel chest (COPD)
Cachexia – very thin patient with muscle wasting (malignancy, cystic fibrosis, COPD)
Cough:
Wheeze (expiratory) – asthma / COPD / bronchiectasis
Stridor (inspiratory) – upper airway obstruction
Treatments or adjuncts around bed – O2 (ILD, COPD) / inhalers or nebulisers (asthma, COPD) /sputum pots (COPD, bronchiectasis)
What do you look for in the hands of people in a Resp exam?
Tar staining Clubbing - lung cancer / interstitial lung disease / bronchiectasis Peripheral cyanosis Flapping tremor - CO2 retention Fine tremor - beta2 agoist use
What do you look for in the head and neck of people in a Resp exam?
Eyes: subconjunctival pallor
Mouth - peripheral and central cyanosis
Lymphadenopathy - ask the patient to sit forward. Submandibular, submental,cervical and supraclavicular lymph nodes
Trachea - deviation (tension pneumothorax)
What do you look for in the resp inspection of the chest?
Shape of the chest - symmetry (kyphoscoliosis) and movements (movement asymmetry may indicate pneumothorax or pleural effusion)
Scars
Pectus excravatum or pectus carinatum
Barrel chest (COPD)
What do you look for in the resp palpation of the chest?
Tracheal position Chest expansion lymph nodes Sacral oedema Apex beat - right heave in cor pulmonale
What do you need to do during resp percussion?
Percuss the following Supraclavicular (lung apices) Infraclavicular Chest wall (3-4 locations bilaterally) Axilla.
Posterior CVS assessment?
Inspect - scars deformity
Palpate for sacral oedema
Percuss for pleural effusion
Auscultate
Posterior resp examination.
Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect of the chest.
GI general eam
Level of consciousness.
Pain
Abdominal distention – ascites / bowel distension / large masses
Masses – may suggest malignancy / organomegalyBody habitus
Jaundice
Pigmentation - haemochromatosis
Scars
Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
Needle track marks – Hepatitis / HIV
Excoriations – pruritus – cholestasis
