C2F CARDIO OSCE

By Faraz Hussain

Aims and Objectives

Overview of the cardiac osce,

-Hx -O/e -DDx -Ix -Mx of common conditions Common OSCE stations Quiz

Hx
CHEST PAIN

SOB (at exertion/rest, orthopnoea, PND)

Palpitations Ankle swelling

Collapse/syncope

PC: CHEST PAIN

S: central

O:Sudden
C: Crushing, heavy R: Neck/jaw, L arm

A: SOB, N+V, Sweating

T: duration >30mins, continuous, progressive E: exacerbating features activity

alleviating features GTN S: 10/10

PMH
IHD

DM
HTN Hypercholesterolaemia

Renal disease
Smoking, ETOH FH

O/e
Intro & consent:

-Wash hands -Expose chest -45o position

1. Inspection
2. Palpation 3. Auscultation

Inspection: General (End of bed)

SOB

PALLOR
SCARS PERIPHERAL OEDEMA (press on leg)

Inspection: Hands
Nails: Clubbing Nicotine/tar staining Splinter haemorrhages Pulse: Rate Rhythm Collapsing pulse BP

Inspection: face and neck

Face: Conjunctive pallor Jaundice Xanthelasma, corneal arcus Central cyanosis (mouth) Neck: JVP raised or not Carotid pulse

Palpation
Apex beat

Heaves/thrills

Auscultation
Mitral area PSM+R to axilla = MR

Tricuspid area
Aortic area ESM + R to carotids = AS Pulmonary area

Back:
Scars

Sacral oedema
Lung bases

Complete Ex
Cover and thank pt

Summarise to examiner (+ve findings)

To complete my examination I would like to requests

bloods, ECG, CXR & ECHO (if murmur present)

DDx chest pain

Cardiac Respiratory Gastro Musculoskeletal

ACS

Pneumonia

Reflux

Rib #

Aortic dissection

PE

Costochondritis

Pericarditis

Pneumothorax

DDx SOB
Cardiac Heart failure Arrhythmia Respiratory Pneumonia Pneumothorax PE Exac. Asthma/COPD Chronic Fibrosis, bronchiectasis, Lung Ca Chronic Anaemia Anxiety

DDx Collapse
Cardiac Neuro Other

Arrythmia

Stroke

Vasovagal

MI

Seizure

Hypoglycaemia

Syncope

Mechanical fall

Always ask about symptoms before, during and after collapse

Ix
Urine & Cultures Bloods Imaging Scopic/biopsy Functional Haematuria, blood cultures FBC, U&Es, LFTs, CRP, TFTs, ABG CXR, ECHO Angiography ECG

5 minute break

Management
ABCDE, resuscitate and stabilise

Hx, Ex, Ix (urine dip, ABG, bloods, ECG, CXR)

Conservative
Medical Interventional/surgical

Stable Angina
Conservative Smoking cessation, exercise, diet modify, wt loss GTN, Aspirin, atenolol, statin Angioplasty, CABG

Medical Interventional/surgical

ACS
Unstable Angina Trop -ve

NSTEMI
STEMI STEMI MONA + PCI

Trop +ve
Trop +ve AND ST-elevation O2, ABCD resus + stabilise GTN 2 sprays Aspirin 300mg Morphine 5-10mg + metoclopramide 10mg PCI/thrombolysis Transfer to CCU O2, ABCD resus + stabilise GTN 2 sprays Aspirin 300mg Clopidogrel 300mg + LMWH (enoxaparin) Transfer to CCU

NSTEMI MONA +Clopidogrel & LMWH

Heart Failure/Acute pulmonary oedema

MONDAY

M:Morphine 5-10mg IV & Metoclopramide 10mg IV

O:O2 N:Nitrates (GTN)

D:Diuretic (furosemide 40-80mg IV)

A:Airway (sit up straight) Y:Yell for help

Tachyarrhythmias

Bradyarrythmias
Pulse < 60bpm, HR<40 dangerous as can result in asystole
CARDIAC IHD affecting SA/AV node Fibrosis of nodal tissue in elderly NON-CARDIAC Iatrogenic: Beta-blockers, digoxin Metabolic: hypothyroidsim, hypothermia

Types: sinus, sick sinus syndrome, 1st degree, 2nd degree

(mobitz type 1&2), 3rd degree heart block

ECG changes 1st degree: prolonged P-R interval 2nd degree Mobitz 1: progressive lengthening of P-R interval then dropped beat 2nd degree Mobitz 2: 2-3 p waves per QRS complex 3rd degree: complete disassociation of P waves and QRS complexes

Brady Mx
ABCDE, resus & stabilize

Any adverse features?

-Heart failure -Hypotension -Reduced GCS -Chest pain Asymptomatic >40HR then monitor If not then get Help Atropine 0.5mg IV Pacing (DC cardiovert)

AF
Definition:

Chaotic, irregular SVT. The SA node has disorganised electrical impulses with the AV node responding intermittently hence an irregularly irregular ventricular rate
Aetiology

Cardiac
MI Valvular disease Heart failure

Non-cardiac
Pneumonia Thyrotoxicosis Alcohol/electrolyte abnormalities (Mg,K)

AF Mx
ABCDE, resus & stabilise

Treat the cause

Call for help Rate control: Propranolol, diltiazem, digoxin

+ Anticoagulation: LMWH, warfarin Rhythm control: DC cardiovert, Amiodarone, Flecanide

Common OSCE stations

AS

MR
Prosthetic valve Pacemaker

AF

Quiz
Bleeped by nurse to r/v pt with high MEWS

ABCDE, resus & stabilise

Hx Ex

DDx
Ix Mx

Conclusion
Chest pain

Systolic murmurs and AF

ABCDE

Questions