Skills OSCE Flashcards
[SKILLS OSCE] Heart size is enlarged if?
Which arteries are prominent in RV enlargement vs LV enlargement ?
The size is equal to or greater than 2x the hemithorax.
It should fit in one lung capacity
CHF»_space; it dilates»_space; elongates and gets bigger
RV enlargement
— pulmonary arteries are prominent and the aorta is diminutive
LV enlargement
—aorta is prominent and the pulmonary arteries are normal
[SKILLS OSCE] What is this?
What could it clue you in to? 2
An enlarged heart
CHF
Pericardial effusion
[SKILLS OSCE] What are the 3 findings on chest X-Ray that could clue you in to left atrial enlargement ?
What about for a RA enlargement?
-
double density sign
— the left atria bulges out behind the right atria on the right side of the heart, so you see two lines on the right side of the heart, the innermost line is the LA -
3rd Mogul
—1st mogul is the aortic knob/arch
—2nd mogul is the main pulmonary artery
—3rd mogul: a convexity between the L pulmonary artery and the left ventricle: = never normal -
splaying of the carina
—increased angle of the left and right bronchi
RA enlargement
— lower right heart border bulges outward to the right
[SKILLS OSCE] Study this —
What does a double density sign indicate?
Left atrial enlargement
[SKILLS OSCE] Study this —
What does splaying of the carina indicate?
Left atrial enlargement
[SKILLS OSCE] Study this chest x-ray showing left atrial enlargement and the third mogul
[SKILLS OSCE] What is this?
Water bottle heart
Could be pericardial effusion
[SKILLS OSCE] What is this?
What could it lead you to think?
Widened mediastinum
Could be TAA or dissection but lacks sensitivity
[SKILLS OSCE] What is this
Bilateral hilar enlargement
CHF: stage 1 redistribution
[SKILLS OSCE] What are Kerley’s lines?
What do they signify?
Fluid in the interstitial
[SKILLS OSCE] What is this?
Vascular redistribution
Early CHF
[SKILLS OSCE] Signs of CHF — 2
Stage II or interstitial edema from increased hydrostatic pressures
—Kerley’s lines
—Peribronchial Cuffing (bronchial wall thickening or fluid around bronchi due to lymphatic congestion
[SKILLS OSCE] What are the purple arrows pointing to?
Kerley lines (interstitial pulmonary edema)
Found in stage II CHF along with donut holes
[SKILLS OSCE]
CXR: batwing or butterfly pattern could indicate?
Fluid in the alveoli produce fan shaped opacities radiating from the hilar region
[SKILLS OSCE] CXR: air bronchogram ?
Air filled bronchi/bronchioles (which are normally dark) become visible by opacification of the surrounding alveoli (white). Always pathological and indicates something other than air is in the alveoli
—consolidation ➡️ pneumonia
[SKILLS OSCE] CXR: What is this?
Pleural effusion
[SKILLS OSCE] What is this?
Air Bronchogram: air filled bronchi/bronchioles (normally dark) become visible by opacification of the surrounding alveoli (white).
Always pathologic and indicates something other than air is in the alveoli (i.e fluid)
[SKILLS OSCE] What is rib notching?
As a result of?
Often seen with?
—enlargement of intercostal arteries
—often seen with coarctation of the aorta
—Coarctation of the aorta is a narrowing/constriction and is recognised by a figure 3 sign on SXR
[SKILLS OSCE]
What are these arrows pointing to?
What is the pathological process that leads to this?
What is the dx and Tx?
Rib notching
Often seen with coarctation of the aorta (present at birth, congenital, narrowing of aorta, presents as infant: claudication in LE when attempting to walk. Asymptomatic until then since demand on the heart is less pre-walking. cyanosis in LE)
—Rib notching occurs because in the adult, coarctation of the aorta leads to a severe narrowing in a portion of the aorta and to overcome this, collateral vessels are created to help deliver blood to the lower extremities.
—The collaterals swell and erode into the bone around them
—DX with CT
—TX w/surgery
[SKILLS OSCE]
What is this?
Descending thoracic aortic dissection (tear)
[SKILLS OSCE]
What does the bottom left indicate?
Anterior wall doesn’t light up so there is a blockage
[SKILLS OSCE]
Familiarise yourself with this CT scan
[SKILLS OSCE]
Aortic dissection
How do you diagnose ?
—most specific/sensitive (think about the images you’ve seen, how were they obtained?)
—other tests
Location categories: Stanford & DeBakey
Recognise this CT image
See disease table
CTAngiography and MRAngiography have the highest specificity and sensitivity
—CXR: widened mediastinum back lacks sensitivity
—Aortography: excellent to visualise but invasive
—ECG to r/o ACS
LOCATION
Stanford:
Type A involves the ascending aorta
Type B does not, just descending
DeBakey
Type 1: aortic arch and beyond (combo)
Type 2: ascending ONLY
Type 3: descending aorta
Acute: <2w from onset
Chronic: >2w from onset”
[SKILLS OSCE]
What is hypertension?
What is normal range?
What is elevated?
What are stage 1 and stage 2?
Hypertension is defined as: >130/>80
Normal: <120/80
Elevated: 120-129/<80
Stage 1: 130-139/80-89
Stage 2: >140/90
[SKILLS OSCE]
What is the recommendation for a fasting lipid panel?
What lifestyle modifications can be made?
What is an abnormal lipid panel? (Total, LDL, HDL, triglycerides)
Every 5 years for adults >20 y/o
Weight loss, change diet to unsaturated fats, increase fibre, plant stanols, increased physical activity
Total cholesterol >200 mg/dL
Triglycerides > 150 mg/dL
LDL >130 mg/dL
HDL <50 mg/dL in women
HDL <40 mg/dL in men
[SKILLS OSCE]
What is this
Left atrial enlargement
Lead V1 has biphasic p wave
Lead II could have camel hump called P mitrale
[SKILLS OSCE]
What is this?
How do you calculate?
V1 S depth + V5/6 R amplitude = > 35mm
[SKILLS OSCE]
What is this?
Acute DVT
[SKILLS OSCE]
ASD
Symptoms kids (3) vs adults (4)
What is the classic finding on PE/auscultation (3) [know this]
What is THE classic finding on EKG? [know this]
Kids
—asymptomatic
—murmur, low pitched
—DOE, fatigue
Adults
—afib, flutter and SVT
—3rd decade of life
—exercise intolerance
—decreased stamina/palps
PE
—RV heave d/t dilated RV
—2/6 systolic ejection murmurs
—wide and fixed split S2 (volume overload, inc. flow across pulmonary valve)
EKG
—crochetage sign
A thrill is a palpable murmur whereas a heave can be a sign of right ventricular hypertrophy. A thrill feels like a vibration and a heave feels like an abnormally large beating of the heart
[SKILLS OSCE]
ASD CXR finding
—enlargement (right side)
—RV forms apex of heart
—increase pulmonary vascular markings
—prominent pulmonary artery
[SKILLS OSCE]
What is this?
Enlarged cardiac silhouette
In the case of VSD
—large shunts will show:
—cardiomegaly
—prominent vascular markings
—enlarged pulmonary arteries
[SKILLS OSCE]
PDA
PE findings
—continuous machine life murmur → doesn’t change w/ position
—displaced LV apex, possible thrill
—low diastolic BP, wide pulse pressure
—bounding pulse
ECG
—can be normal
—can show LA enlargement or LVH
CXR
—prominent pulmonary artery segment, prominent aortic knob along left sternal border
—larger PDA: enlarged LA and LV w/ inc pulm vasc markings
[SKILLS OSCE]
What is this?
Tetralogy of Fallot
[SKILLS OSCE]
What is this?
X-ray of transposition of great arteries
[SKILLS OSCE]
In terms of cardiomyopathies, what can massive T wave inversions mean?
Takotsubo
(Also HCM and Wellens)
[SKILLS OSCE]
HOCM
What do you see on EKG? 3
—LVH
—LAE
—narrow Q waves in inferior and lateral leads
— +/- T wave inversions
[SKILLS OSCE]
What is this?
Deep, narrow dagger Q waves in inferior/lateral leads depicting HOCM
Diffuse T wave inversions
[SKILLS OSCE]
What is this?
ICD
Notice one thick coil going into the RV
This is not a pacemaker
[SKILLS OSCE]
What is this and what does it mean?
[SKILLS OSCE]
What is this?
[SKILLS OSCE]
What are the 4 stages on EKG that determine ischemia?
- Injury: ST elevation
- Ischemia: fully inverted T waves in 24h
- Acute infarction: pathologic Q waves
- Old infarction: ST segment normal. Perm Q waves
With ST depression: concerned about how “deep” the depression is
T wave inversion: not v. Helpful unless the pt has symptoms and cardiac markers OR if the T wave suddenly inverts between EKGs
[SKILLS OSCE]
Describe the EKG progression of a STEMI
[SKILLS OSCE]
Memorise the coronary anatomy and ECG leads
Which leads relate to which coronary arteries?
V1 V2 = more septum
V3 V4 = anterior wall
Lateral = LCx (for this class)
AVR could be left main disease, although it’s a “forgotten” lead
[SKILLS OSCE]
What is the DX of this EKG?
Upper
V1-V4 : ST elevation
Heightened T wave
Not too much reciprocal change
Anterior/septal = LAD
Lower
I and AVL ST elevation
Lateral STEMI
LCx
Reciprocal changes as well
see annotations in notability
[SKILLS OSCE]
What is the DX of this EKG
ST elevation in II, III and AVF
Inferior MI
RCA
RCA = more common because the left main MI patients usually die. The RCA supplies a lot of the right ventricle, still have a lot of LV available to squeeze and preserve cardiac output
Right side supplies a lot of conduction (SA and AV node)
A lot of these patients will present w/ heart block and bradycardia
[SKILLS OSCE]
Right-sided ECG lead placement? When would you do this?
Which lead are you looking at?
Which drug would you not give with this suspected diagnosis?
Confirm inferior MI w/ right ventricular wall involvement
(Confirm this)
II, III, AVF = inferior MI
If someone comes in with this, don’t give nitro, becuase it’s a preload reducer, and you need to INCREASE preload.
Always get a right sided EKG before giving nitro!
Aortic stenosis is the other reason you SHOULDN’T give nitro (could cause syncope)
If you have ST elevation in V4. You have a RV infarct
Acute marginal artery
[SKILLS OSCE]
Right sided EKG lead placement
What are you confirming by doing this?
Which drug do you NOT give?
To confirm RV infarct (inferior)
DO this before giving nitro because RV is preload dependent
Needs preload to SQUEEZE
V4 is the lead to follow
[SKILLS OSCE]
Right sided EKG lead placement
Confirm what this is showing
Inferior MI
[SKILLS OSCE]
What is this?
Which coronary?
Posterior MI
From posterior EKG
RCA or PDA
inferior wall
The original EKG is attached to this side.
There is no ST elevation on this EKG
But it is:
—tall R waves in V1 and V2 and ST segment depression
—should see ST elevation in V7-9
Should not have a prominent R wave in V1 or V2 (bigger than S wave) — indicates RV hypertrophy.
Another reason is posterior MI!
And you have ST depression
[SKILLS OSCE]
What is this
LBBB — lateral leads — “M” or bunny ears
[SKILLS OSCE]
What is this
PVC? Don’t know
[SKILLS OSCE]
What are the ST elevation morphologies?3
—concave
—convex
—obliquely straight
[SKILLS OSCE]
What are the STEMI criteria on EKG?3
General rule of thumb? [know]
ST elevation in 2 contiguous leads: don’t memorise
—Men < 40: 2.5 mm ST elevation in V2 or V-3, 1 mm in any other lead
—Men > 40: 2 mm ST elevation in V2 or V3, 1 mm in any other lead
—Women: > 1.5 mm ST elevation in V2 or V3, 1 mm in any other lead
[know] General rule of thumb
—ST elevation in contiguous leads that fit a coronary artery pattern with:
— > 2 mm ST elevation in precordial leads
—OR > 1 mm ST elevation in limb leads
Use the T-P segment for measuring ST deviation
Only 70% sensitive and 85% specific for acute coronary occlusion
[SKILLS OSCE]
STEMI EKG
What are reciprocal changes?
There is usually RECIPROCAL ST DEPRESSION in the electrically opposite leads.
Ex: If have ST elevation in lead III, can have ST depression to lead aVL
[SKILLS OSCE]
AVR ST elevation
What can it indicate? 2
What are the 2 mechanisms in EKG?
—Left Main insufficiency
—OR diffuse multi vessel disease
Two mechanisms:
—DIFFUSE subendocardial ischemia with ST depression producing RECIPROCAL ST elevation in aVR — 3 vessel disease
—Or infarction of the basal septum producing aVR STEMI
[SKILLS OSCE]
What is this?
Look at AVR
AVR ST elevation
—Left Main insufficiency
—OR diffuse multi vessel disease
Two mechanisms:
—DIFFUSE subendocardial ischemia with ST depression producing RECIPROCAL ST elevation in aVR
—Or infarction of the basal septum producing aVR STEMI
[SKILLS OSCE]
What is considered a STEMI equivalent?
LBBB
—EKG pattern has a ST elevation at baseline making it impossible to use the standard STEMI criteria
—Any new LBBB must be considered as a STEMI equivalent ⭐️
—Sgarbossa’s criteria: (don’t memorise)
1. Discordant ST elevation w/5mm
2. Concordant 1mm
3. Concordant V1-3
[SKILLS OSCE]
What is this?
[CONFIRM]
LBBB
—impulses must travel via the right bundle branch to the RV then to the LV via the septum
—Septal activation is REVERSED
Depolarization vector from right to left produces:
—Tall R waves in the lateral leads
—“M” shaped R wave in the lateral leads due to delay in activation between the RV and LV
—Deep S waves in the precordial leads
—Delayed conduction > 120 msec
Pink EKG is ST elevation in the setting of LBBB (V6)
[SKILLS OSCE]
What is this?
What do you notice in the pattern on the left?
On right right?
Wellen’s syndrome
Pattern A: BIPHASIC T waves (up then down) in V2-3
Pattern B: DEEP INVERTED T waves, symmetrical
Wellens syndrome describes an abnormal electrocardiographic (ECG) pattern, deeply inverted T waves in leads V2 and V3, that are secondary to proximal LAD stenosis.
—Pain-free and elevated cardiac enzymes are usually normal or only slightly elevated.
—MI imminent
[SKILLS OSCE]
What is this?
Benign early repolarisation or J point elevation
—Causes MILD ST elevation
—with TALL T waves in the precordial leads
NORMAL VARIANT
—commonly seen in young, healthy patients
—less common in people > 50
—rare in those > 70 years old.
EKG
—Notching at the J point (fish-hook pattern)
The J point is the junction between the termination of the QRS complex and the beginning of the ST segment (end of depolarization and beginning of repolarization)
—NO RECIPROCAL ST depression
—MIMICS pericarditis or STEMI.
[SKILLS OSCE]
What are the three main cardiac markers?
What are their clinical significances?
Troponin:
—regulatory protein in muscle cells that control interactions between myosin and actin.
—there are three subunits: TnC, TnI, and TnT.
—TnT and TnI are structurally unique and sensitive to myocyte damage. However, other conditions such as myocarditis, hypertensive emergency, and heart failure can also cause cardiac strain and release of markers.
—troponin should be normal, so any troponin level is concerning
Creatine Kinase
—found in heart, skeletal muscle, brain, and many other organs therefore elevation can come with damage to any of these organs
CK-MB
—isoenzyme of CK localized to the heart and improves specificity of its origin
[SKILLS OSCE]
Cardiac markers
How do you approach ordering them and interpreting them? 4
—not released into the serum until a few hours after the onset of myocardial necrosis
—single normal value drawn early does not rule out a MI.
Approach:
1. Draw serial sets of biomarkers:
—a 2nd set 1-2 hours after the first
—then every few hours after
- With coronary occlusion
—the rate of rise is rapid with serial sets of enzymes - If a patient has a STEMI
—total troponin and CK/CK-MB levels useful to gauge size of the infarct
—draw until levels peak - If pt presents w/
—hx of a 1w of chest pain
—+ elevated troponin level
—w/ normal CK/CK-MB
—Q waves on the EKG
= he likely already had evolution of his MI
