OSCE

Question 1

What is pre-test probability?

Answer 1

Pretest probability is the probability of disease (i.e., prevalence) before application of the results of a physical finding.

Question 2

What is usually the likelihood ratio to rule in, and rule out?

Answer 2

LR greater or equal to 3 –> rule in
LR less or equal to 0.3 –> rule out
LR between 0.3 and 3 do not tend to change probability much

Question 3

What is likelihood ratio?

Answer 3

The likelihood ratio (LR) of a physical sign is the proportion of patients with disease who have a particular finding divided by the proportion of
patients without disease who also have the same finding.

Question 4

What is the normal respiratory rate range?

Answer 4

12 - 20 breaths per minute (20 - 24 high normal)

Question 5

What can tachypnea predict?

Answer 5

tachypnea predicts subsequent

cardiopulmonary arrest in hospitalized patients

Question 6

What is Cheyne-Stokes breathing?

Answer 6

Cheyne-Stokes breathing consists of alternating periods of apnea and hyperpnea

Question 7

Whats the difference between tachypnea and hyperapnea?

Answer 7

Tachypnea refers to rapid breathing, especially rapid and shallow breathing. Hyperpnea is abnormally deep breathing, with or without an increase in respiratory rate.

Question 8

Cheyne-Stokes is usually associated with which heart condition and what other conditions?

Answer 8

stable congestive heart failure

Others: hemmorage, infarction, tumors, meningitis and head trauma

Question 9

Whats the prognostic value of C-S breathing?

Answer 9

lower cardiac output, higher pulmonary capillaries wedge pressures, and shorter survival time

Question 10

What is orthopenia?

Answer 10

Orthopnea describes dyspnea that appears when the patient lies down but is relieved when the patient sits up (

Question 11

What is the clinical association with orthopenia?

Answer 11

congestive heart failure

Question 12

Why inspect neck veins?

Answer 12

1. To detect elevated central venous pressure
2. To detect specific abnormalities of venous waveforms, which are characteristic of certain arrhythmias and some valvular, pericardial, and myocardial disorders

Question 13

What are some disorders that may increase CVP, and diastolic pressures of the right side of the heart?

Answer 13

left heart disease, lung disease, primary pulmonary hypertension, and pulmonic stenosis

Question 14

How can be the sternal angle be used as a reference for elevated CVP?

Answer 14

If the top level of the neck veins was more than 3 cm above the sternal angle, CVP is elevated

Question 15

Which side of the neck should be assessed for CVP?

Answer 15

To measure the patient’s venous pressure, the clinician should examine the veins on the right side of the patient’s neck because these veins have a
direct route to the heart.

Question 16

What are the waves seen on a venous pressure tracing?

Answer 16

There are three positive waves (A, C, and V) and three negative waves (x, x′, and y descents):

• A wave represents right atrial contraction
• x descent: right atrial relaxation.
• C wave represents right ventricular contraction
  and closure of the tricuspid valve, which then bulges upward toward the neck veins
• x′ descent occurs because the floor of the right atrium moves downward, pulling away from the jugular veins, as the right ventricle contracts
• V wave represents right atrial filling
• y descent begins the moment the tricuspid valve opens at the beginning of diastole, causing the atrium to empty into the ventricle and venous pressure to abruptly fall

Question 17

What is the positive test for abdominojugular test?

Answer 17

If the CVP rises more than 4 cm water and remains elevated for the entire 10 seconds, the abdominojugular
test is positive

Question 18

What is Kussmaul sign?

Answer 18

The Kussmaul sign is the paradoxic elevation of CVP during inspiration (should fall in normal)

Question 19

What is clinically associated with Kussmaul breathing?

Answer 19

constrictive pericarditis

Question 20

An elevated JVP is helpful in diagnosing what?

Answer 20

elevated left ventricular diastolic pressures and low ejection fraction

Question 21

True or False: a normal JVP is helpful in ruling out low ejection fraction and elevated left ventricular diastolic pressures

Answer 21

False: it is not but abdominojugular test is

Question 22

True or False: low JVP also suggest a low CVP

Answer 22

True

Question 23

When palpating the heart what should be described?

Answer 23

the location, size, timing, and type of precordial movements

Question 24

In the context of heart palpatation, what is the relevance of the supine position?

Answer 24

Supine position is used to locate all precordial movements and to identify whether these movements are abnormally hyperkinetic, sustained, or retracting.

Question 25

In the context of heart palpatation, what is the significance of the left lateral decubitus position?

Answer 25

Used to measure the diameter of the apical pulse (but not to characterise)

Question 26

What are the 4 locations to look for abnormal heart movements?

Answer 26

1. Apex beat/impulse: cardiac impulse farthest
   away from the sternum and farthest down on the chest wall (located near the midclavicular line in the fifth
   intercostal space)
2. Left Lower Sternal Area (Fourth Intercostal Space
   Near Left Edge of Sternum) –> for right ventricle and left atria mvmts
3. Left Base (Second Intercostal Space Near Left Sternum) –> for pulmonary artery
4. Right Base (Second Intercostal Space Near Right Edge of Sternum) and Sternoclavicular Joint –> for ascending aortic aneurysm

Question 27

What is sustained systolic mvmt/apex beat?

Answer 27

The sustained movement is an abnormal outward movement that begins at S1 but, unlike normal and hyperkinetic movements, extends to S2 or even
past it before beginning to descend to its original position.

Question 28

What is the clinical associations of sustained systolic mvmt?

Answer 28

Sustained apical movements are always abnormal, indicating either pressure overload of the
left ventricle (e.g., aortic stenosis), volume overload (e.g., aortic regurgitation, ventricular septal defect), a combination of pressure and volume overload
(combined aortic stenosis and regurgitation), severe cardiomyopathy, or ventricular aneurysm.

Question 29

What is a traditional sign of an enlarged heart?

Answer 29

an abnormally displaced apical impulse, ejection fraction reduced, LV end-diastolic volume and PCWP is increased

Question 30

What is the significance if the apical impulse is greater than 4 cm?

Answer 30

Dilated heart