OSCE - Cardiovascular

Question 1

Examination - JACCO

Answer 1

• Jaundice - Yellowing of skin and sclera of eyes. Can be caused by the build-up of Bilirubin (yellow/brown - the product of red blood cell breakdown):
  
  • Gallstones
  • Alcoholic Liver Disease
  • Pancreatitis
  • Hepatitis
  • Sickle Cell
• Anaemia - Pallor in mucous membranes or dull, pale skin caused by lack of red blood cells.
• Cyanosis - Bluish discolouration of the skin due to poor circulation/inadequate oxygenation of the blood. Peripherally caused by low O₂ in the red blood cells, or problems getting oxygenated blood to the body. Cold temps. can lead to blood vessel narrowing & temporarily blue-tinged skin. Central cyanosis is more serious and can be caused by low cardiac output.
• Clubbing - Deformity of the finger or toenails associated with a number of diseases, mostly of the heart & lungs.
• Oedema - Condition characterised by an excess of watery fluid collecting in the cavities or tissues of the body. Note lower leg/ankle (?sacral?) oedema could be an indication of heart failure

Question 2

Examination - Hands

Answer 2

• Warm - indicative of good perfusion.
• Dry - indicative of dehydration, not clammy.
• Perfused - pallor or cyanosis?
• Tremor - indicative of neurological conditions such as Parkinsons.
• Splinter Haemorrhage - indicative of infectious endocarditis. ?fever/heart murmur/petechiae/anaemia.
• Nicotine staining - note yellowing of fingers.
• Xanthomas - fatty growths develop under the skin, caused by high levels of blood lipids/fats, a symptom of an underlying condition - hyperlipidaemia/high cholesterol.
• Capillary refill - over 2 seconds indicates of poor perfusion

Question 3

Examination - Pulses

Answer 3

• Rhythm
• Rate:
  
  • too fast to count - SVT/VT
  • fast - tachycardia
  • normal
  • slow - bradycardia
  • too slow - ? about to die
• Regularity:
  
  • regular
  • irregular
  • regularly irregular - the same pattern repeated - heart blocks/3:1 or 4:1 block
  • irregularly irregular - completely irregular - AF
• Character:
  
  • full
  • normal
  • weak
  • thready - indicated low BP due to a decrease in cardiac output
• Radial-radial delay - a narrowing and/or increased resistance between the brachiocephalic trunk and the left subclavian artery

Question 4

Examination - Blood Pressure

Answer 4

• Technique(manual)
• Correct cuff size
• Sitting
• Standing

Question 5

Examination - Face

Answer 5

• Xanthelasma - cholesterol filled skin lesions, indicates high cholesterol
• Arcus Senilis - a cloudy opaque arc/circle around the edge of the eye - often in elderly, indicates high cholesterol, can be normal in over 65’s
• Anaemia - pallor in mucous membranes or dull, pale skin caused by lack of red blood cells
• Jaundice - yellowing of the skin and the whites of the eyes - caused by build-up of yellow bilirubin - causes include:
  
  • gallstones
  • alcoholic liver disease
  • pancreatitis
  • hepatitis
  • sickle cell disease

Question 6

Examination - Neck

Answer 6

• JVP:
  
  • head turned away from the midline
  • look for pulsating waveform between the two heads of the Sternocleidomastoid
  • usually only just visible, so if raised indicates R-heart failure/fluid overload
• Carotid bruits:
  
  • gently listen over each carotid artery
  • abnormal sound - bruit(vascular murmur) reflects turbulent blood flow - indicates carotid artery disease
  • NOT essential to auscultate for carotid bruits if any concern of danger to the patient by causing a rupture which

Question 7

Inspection

Answer 7

• Scars - evidence of previous cardiac surgery or trauma?
• Pacemake/ICD - yes/no?
• Lesions/rashes - comment/note
• Bruising or injuries - Indicating recent trauma

Question 8

Palpation

Answer 8

• Apical beat identified:
  
  • Usually felt with Pt leaning to 45°
  • Position - 5^th intercostal space, left midclavicular line
  • Character - tapping(normal) or heaves/thrills(heart is working hard)
  • Enlargement of the heart causes apex to be displaced downwards and laterally
  • Enlargement caused by:
    
    • enlarged muscle volume but normal chamber size - ‘hypertrophy’
    • enlarged chamber volume with thinning of the ventricular wall - ‘dilated cardiomyopathy’
  • Displaced apex could be due to:
    
    • enlarged heart - HTN or LVF/RVF
    • shifted heart - Tension Pneumothorax/lung disease
  • Heaves - heart pushes blood against much more resistance than it is used to, it’s wall’s become thickened and that thickened wall touches the chest wall when it contracts each time
  • Thrills - when blood flows across a narrowed valve in the heart, it produces a sound which is called a murmur. When this murmur grows louder in intensity it can be felt when we touch the chest wall. It is known as a palpable murmur
  • Heaves/thrills - causes include:
    
    • increased resistance to flow from the left or right ventricles(aortic/pulmonary stenosis)
    • blood flowing back into the heart through an incompetent valve(aortic/pulmonary incompetence)
• Tenderness - note

Question 9

Auscultation

Answer 9

• Good technique
• All areas auscultated - Aortic - Pulmonary - Tricuspid - Mitral

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• Knowledge of normal/abnormal sounds:
  
  • ​​ Systolic murmur - the noise of turbulent blood flow during systole indicates blood is either flowing back into the atria through the atrioventricular valves that are incompetent(not closing properly), or that blood is meeting increased resistance leaving the ventricles due to narrowing of the aortic and pulmonary valves.
  • Diastolic murmur - suggestive of ARMS - Aortic Regurgitation Mitral Stenosis, or resistance to blood flow from the atria to the ventricles.

Question 10

Further Tests

Answer 10

• ECG

Question 11

Essential Observations

Answer 11

• BM
• BP