Aims and Objectives Requires some basic knowledge of clinical examinations • Clinical examination station (OSCE) • One way to prepare: ‘Retrospective approach’ • Cardiovascular examination: 2 cases • Respiratory examination: 2 cases • Duration: 70 mins • Slides and recordings: www.bitemedicine.com/watch • Other common OSCE cases available in previous and upcoming webinars • Aim of the week is to cover most of the common scenarios • 2
Clinical examination station: how to prepare? ‘Retrospective approach’ EXAMINATION Perform each step of the • 1. Formulate an OSCE Cases List ROUTINE routine confidently Pick up on signs • 2. Prepare your ‘VIVA’ for those cases Positive signs of diagnosis • PRESENTATION Present findings • ‘Typical’ findings presentation • systematically Risk factors List appropriate • • differentials based on Signs of decompensation • findings List of differentials • VIVA Answer questions • Complications • systematically How would you investigate this patient? • Explain your thinking • How would you manage this patient? • 3
Clinical examination station: how to prepare? ‘Retrospective approach’ EXAMINATION Perform each step of the • 3. Finalise your examination routine ROUTINE routine confidently Pick up on signs • Each step of the routine • Signs you are looking for • Your speech • PRESENTATION Present findings • systematically 4. Practice your examination routine List appropriate • on friends differentials based on findings 5. Go to the wards/clinics looking for VIVA Answer questions • your cases systematically Explain your thinking • 4
Cardiovascular examination: OSCE Cases list What cases could come up? 1. Mitral regurgitation 2. Aortic stenosis 3. Prosthetic heart valves: aortic, mitral or both 4. Stable chronic heart failure 5. Ischaemic heart disease: CABG scars This is not a definitive list But by preparing for these you will be better at: • Your exam routine • Looking out for important signs • Formulating your findings systematically • Tackling the VIVA • 5
How to present your findings? I performed a cardiovascular examination on this patient If you have an idea, then Who has signs suggestive of mitral regurgitation back yourself from the start. • It gets the examiner listening My main positive findings are: 1. XXX 2. YYY My relevant negative findings are: RELEVANT negatives 1. XXX (Risk factors) 2. YYY (Signs of decompensation) 3. ZZZ (POSSIBLE associated features) Overall, this points towards a diagnosis of mitral regurgitation with 99% of the time your patient no signs of decompensation will be STABLE 6
Cardiovascular examination: Case 1 Central Peripheral Auscultation Pulse Pansystolic murmur • Irregularly irregular • Loudest at the mitral region • Exacerbated on patient lying on • their L side and on held expiration Radiation to axilla • 7
Question 1 8
Cardiovascular examination: Case 1 – Mitral regurgitation What is a pan-systolic murmur? • Lasts entire duration between S1 & S2 • Does not change in intensity 9
Cardiovascular examination: Case 1 – Mitral regurgitation What is a pan-systolic murmur? • Lasts entire duration between S1 & S2 • Does not change in intensity 10
Cardiovascular examination: Case 1 – Mitral regurgitation Why is mitral regurgitation associated with an irregularly irregular pulse? Mitral regurgitation = MV valve doesn't close • properly (1) 11
Cardiovascular examination: Case 1 – Mitral regurgitation Why is mitral regurgitation associated with an irregularly irregular pulse? Mitral regurgitation = MV valve doesn ’ t close • properly So when the LV starts to contract, blood is • regurgitated from the LV back into the LA (1) 12
Cardiovascular examination: Case 1 – Mitral regurgitation Why is mitral regurgitation associated with an irregularly irregular pulse? Mitral regurgitation = MV valve doesn ’ t close • properly So when the LV starts to contract, some blood is • regurgitated from the LV back into the LA Over time, LA becomes dilated • (1) 13
Cardiovascular examination: Case 1 – Mitral regurgitation Why is mitral regurgitation associated with an irregularly irregular pulse? Mitral regurgitation = MV valve doesn ’ t close • properly So when the LV starts to contract, some blood is • regurgitated from the LV back into the LA Over time, LA becomes dilated à LA starts to • remodel à affects the electrical conduction This leads to atrial fibrillation (irregularly irregular • pulse) Summary: In chronic MR, the L atrium remodels à this (1) affects electrical conduction through the heart 14
Cardiovascular examination: Case 1 – Mitral regurgitation Please present your findings? I performed a cardiovascular examination on this patient who has signs suggestive of MITRAL REGURIGTATION My main positive findings are: I palpated an irregularly, irregular pulse, suggestive of atrial fibrillation • On auscultation, I could hear normal 1 st & 2 nd heart sounds with a systolic murmur between S1 • & S2 The systolic murmur was: • Character: pansystolic • Region: loudest over the mitral region • Augmentation: end-expiration with the patient lying on their left side • Radiation: axilla • 15
Cardiovascular examination: Case 1 – Mitral regurgitation Please present your findings? My relevant negative findings are: No signs of vascular risk factors e.g. tar staining, tendon xanthomata • No peripheral stigmata of infective endocarditis • No scars to suggest coronary artery bypass graft or valve replacement • No signs of decompensation e.g. pulmonary or peripheral oedema • This points towards a diagnosis of grade 3 mitral regurgitation complicated by atrial fibrillation 16
Cardiovascular examination: Case 1 – Mitral regurgitation What are your differentials? 1. Mitral regurgitation Acute Chronic Infective endocarditis Ischaemic injury to L ventricle à dilated MV annulus Rupture of papillary muscle (e.g. post MI) Calcification of MV annulus Rheumatic heart disease 2. Aortic stenosis Ejection systolic murmur with radiation to carotids • 3. Tricuspid regurgitation Pansystolic murmur • Heard loudest over lower L sternal edge • Augmented on held INSPIRATION • No radiation • Rarer • 17
Cardiovascular examination: Case 1 – Mitral Regurgitation What are possible complications of mitral regurgitation Complications from the valve Infective endocarditis • Complications from impaired outflow Left ventricular failure • Atrial fibrillation • 18
Cardiovascular examination: Case 1 – Mitral regurgitation How would you investigate this patient? Bedside Basics observations: HR, BP, RR, SpO2 • Urine dip: glycosuria for diabetes • ECG: • AF • P-mitrale (broad, notched P waves): sign of dilated LA • (2) Bloods Inflammatory markers: CRP and ESR for infective • endocarditis BNP : raised if associated heart failure • 19
Cardiovascular examination: Case 1 – Mitral regurgitation How would you investigate this patient? Imaging CXR • L atrial enlargement • Signs of heart failure (ABCDE) • ECHO: gold standard test to diagnose & assess severity • Severe: Jet width > 0.7cm, regurgitant volume > • 60mls Special Coronary angiography: measure gradient across valve • and assess for concomitant coronary artery disease (3) 20
Cardiovascular examination: Case 1 – Mitral regurgitation How would you manage this patient? Conservative Improve cardiovascular risk factors e.g. smoking cessation • Medical Anticoagulation for AF • Manage heart failure if present • ACEi, beta-blockers, diuretics • Surgical Valve repair or replacement indicated if: • Symptomatic • Severe LV dilation • Significantly reduced LVEF • New-onset AF • 21
Grading murmurs Freeman & Levine Grading for heart murmurs Grade 1 : Faintest murmur • Grade 2: Faint murmur • Grade 3: Loud murmur, no thrill • Grade 4: Loud murmur + palpable thrill • Grade 5: Murmur heard with stethoscope partially on chest + thrill • Grade 6: Murmur heard with stethoscope held off chest • 22
Cardiovascular examination: Case 2 Peripheral Central (4) (5) Auscultation • Bibasal crackles (6) 23
Question 2 24
Cardiovascular examination: Case 2 – Congestive cardiac failure Please present your findings? I performed a cardiovascular examination on this patient who has signs suggestive of CHRONIC HEART FAILURE My main positive findings are: Tar staining • Finger prick marks suggesting blood glucose monitoring • Peripheral oedema up to knees • I also noticed a vertical 6cm scar on the neck along the distribution of the carotid artery • suggestive of a carotid endarterectomy scar On auscultation of the lung bases: bibasal crackles • 25
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