OSCE - Cardio Exam

Question 1

What is radio-radial delay and what does it indicate?

Answer 1

1. loss of synchronicity between radial pulse on each up, pulse occurring at different times.

Question 2

How to assess for radio-radial delay?

Answer 2

1. palpate both radial pulses simultaneously.
2. NORMAL –> both pulses occur at the same time
3. ABNORMAL –> pulses out of sync

Question 3

What causes radio-radial delay? (3)

Answer 3

1. Subclavian artery stenosis (e.g. compression by a cervical rib)
2. Aortic dissection
3. Aortic coarctation

Question 4

What is a collapsing pulse?

Answer 4

Pulse which rapidly increases and subsequently collapses.

Question 5

How to assess for collapsing pulse?

Answer 5

1. Ask if there is any pain in the right shoulder
2. palpate radial pulse (with right hand wrapped around patients wrist)
3. palpate brachial pulse (with left hand)
4. Raise patients arm above their head briskly
5. palpate for collapsing pulse: blood rapidly empties during diastole - should feel tapping impulse through muscle bulk of arm .

Question 6

Causes of collapsing pulse?

Answer 6

1. Normal physiological states (fever, pregnancy)
2. cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
3. high output states (e.g. anaemia, arteriovenous fistulae, thyrotoxicosis)

Question 7

Types of pulse character and their associations? (4)

Answer 7

1. Normal
2. Slow rising
   –> aortic stenosis
3. bounding
   –> aortic regurgitation
   –> CO2 retention
4. Thready
   –> intravascular hypovolaemia (e.g. sepsis)

Question 8

What is a NARROW pulse pressure?

Answer 8

less than 25mmHg of difference between systolic and diastolic blood pressure.

Question 9

Causes of NARROW pulse pressure? (3)

Answer 9

• aortic stenosis
• congestive heart failure
• cardiac tamponade

Question 10

What is a wide pulse pressure ?

Answer 10

More than 100mmHg difference between systolic and diastolic.

Question 11

Causes of WIDE pulse pressure?

Answer 11

• aortic regurgitation
• aortic dissection

Question 12

What condition might a difference between blood pressure in both arms indicate?

Answer 12

• if difference if more than 20mmHg
• AORTIC DISSECTION

Question 13

What does a raised JVP indicate?

Answer 13

• Venous hypertension

Question 14

Causes of raised JVP? (3)

Answer 14

1. Rught sides heart failure
   –> due to pulmonary HTN, from COPD or ILD
2. Tricuspid regurgitation
   –> infective endocarditis
   –> rheumatic heart disease
3. Constrictive pericarditis
   –> often idiopathic
   –> some possible underlying causes: rheumatoid arthritis, TB

Question 15

What does a positive hepatojugular reflux result suggest?

Answer 15

• right ventricle unable to accommodate an increased venous return?

Question 16

Examples of conditions that may frequently produce a positive hepatojugular reflux test?

Answer 16

• constrictive pericarditis
• RV failure
• LV failure
• restrictive cardiomyopathy

Question 17

Hazy white, grey or blue opaque ring located in the peripheral cornea

Answer 17

Corneal arcus
- presence in patients under 50 may suggest hypercholesteromaemia

Question 18

Common inflammatory condition affecting corners of mouth

Answer 18

Angular stomatitis
- wide range of causes
- may indicate iron deficiency

Question 19

High arched palate is a feature of what condition?

Answer 19

Marfan’s syndrome
- associated with mitral / aortic valve prolapse and aortic dissection

Question 20

Valve locations

Answer 20

Mitral valve: 5th intercostal space in the midclavicular line.

Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.

Pulmonary valve: 2nd intercostal space at the left sternal edge.

Aortic valve: 2nd intercostal space at the right sternal edge.

Question 21

Coarse crackles are suggestive off:

Answer 21

Pulmonary oedema
–> associated with left ventricular failure

Question 22

Absent air entry and stony dullness on percussion are suggestive of:

Answer 22

–> underlying pleural effusion
—-> associated with left ventricular failure

Question 23

Summary of further assessments and investigations you might do?

Answer 23

1. BP
2. Peripheral vascular examination
3. ECG (arrhythmia or MI)
4. Dipstick urine (proteinuria, haematuria –> HTN)
5. Cap blood glucose (underlying DM, risk factor CVD)
6. Fundoscopy (if concerns about malignancy HTN, papilloedema)

Question 24

Typical signs seen with aortic regurgitation?

Answer 24

1. Corrigan’s sign
   –> visible distention and collapse of carotid arteries in the neck
2. De Musset’s sign
   –> head bobbing with each heartbeat
3. Quincke’s sign
   –> pulsations in nail bed with each heart beat, when nail bed lightly compressed
4. Traube’s sign
   –> pistol shot sound heart when stethoscope over femoral artery during systole and diastole
5. Muller’s sign
   –> uvula pulsations seen with each heart beat
6. Wide pulse pressure

Question 25

Causes of aortic regurgitation?

Answer 25

Diseases affecting valve:
- congenital bicuspid aortic valve
- rheumatic heart disease
- infective endocarditis

Aortic root dilatation:
- aortic dissection
- connective tissue diseases (e.g. Marfans)
- aortitis

Question 26

Management of aortic regurgitation?

Answer 26

1. Vasodilator therapy (BB, CCB)
2. Aortic valve replacement
   –> TAVI if high risk