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INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Internal Medicine OSCE Book

JONATHAN LAXTON (EDITOR)

2014 EDITION Internal Medicine OSCE Book JONATHAN LAXTON (EDITOR) University of Manitoba UNIVERSITY OF MANITOBA 0

University of Manitoba

University of Manitoba UNIVERSITY OF MANITOBA 0

UNIVERSITY OF MANITOBA

0

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Table of Contents

Table of Contents

1

Cardiology

4

General Cardiology

4

Approach to the EKG

4

Jugular Venous

Pulsation (JVP)

8

Valvular Diseases

10

Approach to a Murmur

10

Right Heart Murmurs

11

Aortic Regurgitation (AR)

12

Pulmonary Regurgitation (PR)

14

Mitral Stenosis (MS)

15

Tricuspid

Stenosis (TS)

17

Tricuspid Regurgitation (TR)

17

Mitral

Regurgitation (MR)

18

Mitral

Valve Prolapse (MVP)

20

Aortic

Stenosis (AS)

21

Hypertrophic Obstructive Cardiomyopathy (HOCM)

23

Myocardium & Pericardium

24

Pericardial Compressive Syndromes

24

Ventricular Septal Defect (VSD)

26

Atrial Septal Defect (ASD)

27

Heart Failure (HF)

28

Acute Coronary Syndrome (ACS)

30

Amiodarone Counselling

32

Vasculature

34

Peripheral Vascular Disease

34

Hypertension

36

Abdominal Examination for Hypertension

38

Abdominal Aortic Aneurysm (AAA)

39

Aortic

Dissection

40

Lower Extremity Ulcers Differentiation

 

41

Neurology

42

General Neurological Examination Issues

 

42

Neurological Screening Examination

45

Central Nervous System

46

Pupillary Examination

46

Diplopia Examination

48

Myasthenia Gravis

50

Approach to the Red Eye

52

Cranial Nerve V (Trigeminal Nerve)

54

Cranial Nerve VII (Facial Nerve)

56

Cranial Nerve VIII (Vestibulocochlear Nerve)

58

Dysphagia (Cranial Nerves IX, X & XII)

 

61

Spinal Cord Syndromes

63

Non-Cerebellar Ataxia

66

Cerebellar Ataxia

68

Tremor

70

Parkinson’s Disease

72

Initial Examination of a CVA

74

Stroke Syndromes

77

Anti-Epileptic Drug Counselling

79

Lumbar Puncture

83

Peripheral Nervous System (PNS)

84

Major Nerve Roots

84

Brachial Plexopathies

86

Median Nerve/Carpal Tunnel Syndrome

 

88

Radial Nerve Examination

90

Ulnar Nerve Examination

92

Femoral Nerve Examination

94

Peroneal Nerve Examination

96

Tibial Nerve Examination

97

Critical Care & Toxicology

98

Approach to a Comatose Patient

98

Alcohol Use: Diagnosis & Counselling

101

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2014 EDITION

Evaluation of Patient with Acute Intoxication

103

Assessment of Neurological Death

105

Shock

107

Endocrine

110

Thyroid

Examination

110

Thyroid

Nodules

112

Hypothyroidism (Peripheral Manifestations)

114

Hyperthyroidism (Peripheral Manifestations)

115

Cushing’s Syndrome

117

Adrenal Insufficiency

119

Acromegaly

120

Diabetic

Screening Examination

121

Diabetic

Foot Ulcers (DFU)

123

Normal Pregnant Patient

125

Osteoporosis

127

Peripheral Manifestations of Dyslipidaemia

129

Statin Counselling

131

Anti-Thyroid Drug Counselling

132

Respiratory

133

Approach to CXRs

133

Approach to PFTs

135

Approach to ABGs

137

Haemoptysis

140

Pulmonary Hypertension (PHT)

142

Obstructive Sleep Apnoea (OSA)

144

Pulmonary Embolism (PE) & Deep Venous Thrombosis (DVT)

146

Smoking Cessation

147

Chronic Obstructive Pulmonary Disease

(COPD)

149

Pleural Effusions

151

Pneumonia or Consolidation

153

Pneumothorax

155

Sarcoidosis

156

Digital Clubbing

158

Pulmonary-Renal Syndromes

159

Thoracocentesis

161

Rheumatology

162

Autoimmune Disorders

162

Systemic Lupus Erythematosus (SLE)162

Systemic Sclerosis (SSc or Scleroderma)

 

164

Approach to Monoarticular Arthritis

166

The Rheumatoid Hand

168

Rheumatoid Arthritis

170

Inflammatory Back Pain

172

Corticosteroid Counselling

174

Specific Joints

177

Neck Pain Examination

177

Elbow Examination

179

Shoulder Examination

181

Lower Back Pain Approach

184

Hip Examination

186

Knee Examination

189

Ankle Examination

192

Arthrocentesis

195

Geriatrics

196

Gait Disorders

196

Falls Examination

198

Delirium

199

Infectious Diseases

201

Infective Endocarditis

201

Bacterial Meningitis

204

Initial Examination of an HIV-Infected

Patient

205

Influenza Vaccine Counselling

208

Pneumococcal Vaccine Counselling

210

Hepatology and Gastroenterology

211

Hepatomegaly

211

Stigmata of Chronic Liver Disease

212

Ascites

214

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

215

Extraintestinal Manifestations of IBD 217

Acute Abdominal Pain

Malnutrition: Subjective Global Assessment

219

NSAIDs Counselling

222

Paracentesis

224

Nephrology

226

Acute Kidney Injury (AKI) & Chronic

Kidney Disease (CKD)

226

Approach to Anasarca or Oedema

228

Hypovolaemia

230

Central Venous Catheter Insertion

231

Haematology

233

Splenomegaly

233

Lymphadenopathy

235

Anaemia

238

Anticoagulation Counselling

240

Counselling for Blood Transfusions

244

Oncology

246

Superior Sulcus Tumour (Pancoast Tumour)

246

Examination for Potential Malignancy247

Melanoma

251

References

252

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Cardiology General Cardiology Approach to the EKG

Ernest Inegbu (2012)

Consistent Approach

Check name, date & calibration

Rate, rhythm & axis

Conduction (intervals), QRS complex, QT c , hypertrophy & ischaemia

Rate

Normal 60-100bpm

o

>100bpm tachycardia

o

<60bpm bradycardia

4 possible approaches:

o

Count number of little squares between 2 beats & divide into

1500

o

Count number of big squares

between beats and divide into

300.

o

Remember the following sequence to apply to each big square between 2 consecutive beats: 300, 150, 100, 75, 60

o

Irregular or extremely bradycardic count number of beats in rhythm strip and multiply by 6.

Rhythm

Regular vs. irregular

Sinus rhythm:

o

P wave before every QRS

o

Upright p wave axis in lead II

o

Biphasic p wave lead V 1

Flutter waves (F waves) - ~300bpm with saw-wave pattern

 Flutter waves (F waves) - ~300bpm with saw-wave pattern  Irregular rhythm without distinct p

Irregular rhythm without distinct p waves atrial fibrillation (AF) or ventricular fibrillation (VF).

P waves not upright in II likely from ectopic foci other than sinus node.

Axis (QRS)

Normal +90° to -30°.

Normal = upright axis in I & II

LAD (-30°C) QRS upright in I & downward in II.

o LVH, LBBB, inferior MI, WPW, LAFB

RAD (≥90°) – QRS downward in I & upwards in II.

o RVH, PE, COPD, lateral MI, WPW, LPFB.

Conduction

PR Interval

Normally 0.12-0.2s (2-5 small squares) from beginning of p wave to beginning of QRS complex

Short PR – WPW (δ wave), junctional rhythm

complex  Short PR – WPW (δ wave), junctional rhythm  Long PR – AV conduction

Long PR AV conduction delay

QRS Complex

Normal <0.12s (<3 small squares)

o Partial bundle branch blocks between 0.10-0.12s

LBBB broad, slurred, monophasic R in leads I, V 5-6 & aVL

RBBB rSR´ in V 1 & V 2

6 & aVL  RBBB – rSR´ in V 1 & V 2 QT Interval 

QT Interval

 Normally <½ R-R interval for HR 65- 90bpm.  Measured at onset of QRS
Normally <½ R-R interval for HR 65-
90bpm.
Measured at onset of QRS to onset of T
wave.
=
Normal <0.42s ♂ & <0.43s ♀
↑QT c :
o
Drugs – amiodarone, sotalol,
TCA, Abx (levofloxacin,
azithromycin)
o
Hypocalcaemia, hypothyroidism,
hypothermia, ICH

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Chamber Hypertrophy

Right Atrial Enlargement (RAE)

P pulmonale tall p wave >2.5mm in lead

II

 P pulmonale – tall p wave >2.5mm in lead II Left Atrial Enlargement (LAE) 

Left Atrial Enlargement (LAE)

P mitrale = wide p wave >2.5mm in lead

II

V 1 biphasic p wave or negative p wave >0.04s (>1 small square)

p wave or negative p wave >0.04s (>1 small square) Right Ventricular Hypertrophy (RVH)  R/S

Right Ventricular Hypertrophy (RVH)

R/S ratio V 1 >1

R/S ratio in V 6 <1

R in V 1 >7mm, S in V 5 or V 6 ≥7mm

COPD, PS, transposition of great arteries, ASD, VSD, tetralogy of Fallot, MS, TR

of great arteries, ASD, VSD, tetralogy of Fallot, MS, TR Left Ventricular Hypertrophy (LVH)  Praecordial

Left Ventricular Hypertrophy (LVH)

Praecordial & limb leads:

o

S in V 1 or V 2 + R in V 5 or V 6

>35mm

o

Largest R or S in limb leads

≥20mm

o

R in V 5 or V 6 >30mm, S in V 1 or V 2 ≥30mm

o

R in aVL >11mm

S in V 1 or V 2 ≥30mm o R in aVL >11mm  Long-standing HTN,

Long-standing HTN, HCMP, AS/AI, coarctation of aorta

Ischaemia

HTN, HCMP, AS/AI, coarctation of aorta Ischaemia Q Wave  Significant Q wave >0.04s wide or

Q Wave

Significant Q wave >0.04s wide or at least ⅓ of the R & present in >1 lead

R Wave Progression

R wave should progress from negative to positive in praecordial leads

Mostly upright in V 4 & R 3mm by V 3

PRWP = R wave in V 2 ≤3mm

Old anteroseptal MI, LVH, RVH/COPD, LBBB, WPW, CMP

ST-Segments

Normally isoelectric (same direction as QRS)

ST depression

o Ischaemia, subendocardial infarction or acute true posterior MI, digitalis effect, hypokalaemia

ST elevation

o Infarction, coronary artery spasm, PE, HCMP, repolarisation abnormality, early repolarisation, myopericarditis, post-tachycardia or post-pacing, CNS injury (SAH).

Dominant R Wave in V 1 or V 2

RVH, HCMP, true posterior MI, RBBB, Duchenne’s muscular dystrophy, WPW, dextrocardia

Lead misplacement or normal variant

Disease-Related EKG Findings

Pericarditis

Diffuse ↑ST with upward concavity, PR depression (except aVR ST depression with ↑PR), TWI

Stages:

o

↑ST & ↓PR

o

ST & PR normalise

o

Diffuse TWI

o

TW normalise

Pericardial effusion - ↓ QRS amplitude, electrical alternans

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

INTERNAL MEDICINE OSCE BOOK 2014 EDITION Pulmonary Embolism  AF/AFL, sinus tachycardia  RV strain –

Pulmonary Embolism

AF/AFL, sinus tachycardia

RV strain tall R wave in V 1 , peaked p waves, ST changes

RBBB

RAD, p pulmonale

S 1 Q 3 T 3 (non-specific) S wave I, Q wave in III & TWI in III

Hyperkalaemia

Peaked T waves (>10mm), ↑ PR interval

Loss of p waves

↑ QRS width

↑ ST

Sine wave pattern (severe)

PEA/VF (very severe, obviously)

Most findings do not correlate with actual K + level

Most findings do not correlate with actual K + level Hypokalaemia  Flattened TW  U

Hypokalaemia

Flattened TW

U waves (found after T & before p)

Prolonged PR

QT c & ST

PVCs, VT, VF

PR  ↑ QT c & ↓ ST  PVCs, VT, VF Hypercalcaemia  ↓ QT

Hypercalcaemia

QT c , ST & J wave

VF Hypercalcaemia  ↓ QT c , ↓ ST & J wave Hypocalcaemia  ↑ QT

Hypocalcaemia

QT c , ST

ST & J wave Hypocalcaemia  ↑ QT c , ↑ ST Hypothermia  Sinus bradycardia

Hypothermia

Sinus bradycardia

Osborne J wave – “camel bump”

QT c , AF

Osborne J wave – “camel bump”  ↑ QT c , AF Wolf-Parkinson White (WPW) 

Wolf-Parkinson White (WPW)

Shortened PR <0.1s, δ wave

Widened QRS

R in V 1 & Q in I & aVL

Concealed – normal PR with no δ wave

Digitalis Effect

Effect:

o ST or inversion (scooping Salvador dali)

o QT c

o ↓ ST or inversion (scooping – Salvador dali) o ↓ QT c  Toxicity: o

Toxicity:

o AV block

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2014 EDITION

o

AV dissociation

o

PAT with block

o

PVC, bigeminy, trigeminy, VT, VF

o

Accelerated junctional escape

o

Bidirectional VT

TCAs

ST, flattened or inverted TW

↑ QT c , U wave

AV & IV blocks, VT

↑ QRS width

Low Voltage EKG

QRS amplitude (R + S) ≤5mm in all limb leads & ≤10mm in all praecordial leads

Aetiology:

o

COPD

o

Obesity

o

Thick chest wall

o

Pericardial effusion

o

Pleural effusion

o

Hypothyroidism/myxoedema

o

Hypothermia

o

CMP restrictive or infiltrative

o

Diffuse CAD

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Jugular Venous Pulsation (JVP)

Shirley Paski (Original)

Aetiology of Elevated JVP

Cardiac

Valvular disease

o TS, TR & PR

Myocardial disease

o

RV failure

o

RV hypertrophy

Pericardial disease

o

Constrictive pericarditis

o

Cardiac tamponade

Conduction system

o AV dissociation (3° AVB or VT)

Extra-Cardiac

Hypervolaemia

Pulmonary

o

Massive PE (usually with RV failure/strain)

o

Pulmonary hypertension

SVC obstruction

Abnormal JVP Waveforms

Dominant a Wave

Tricuspid stenosis (with very slow y descent)

Pulmonary hypertension

Cannon a Wave

Complete AVB

Paroxysmal nodal tachycardia with reterograde atrial conduction

VT with retrograde atrial conduction or AV dissociation

Dominant v Wave

TR utility of cv wave for detecting moderate-to-severe TR (+LR 10.9)

Absent x Descent

AF

Exaggerated x Descent

Acute cardiac tamponade

Constrictive pericarditis

Sharp y Descent

Severe TR

Constrictive pericarditis

Slow y Descent

TS

Right atrial myxoma

Patient Position

Patient lying supine on examination table, initial angle 30-45°

Turn patient’s head slightly away from examiner (may help to tilt chin upwards as well).

Ensure adequate lighting.

Inspection

Location of JVP

Found between 2 heads of sternocleidomastoid (insertion at clavicle & sternum)

Inspect superiorly from this position towards ear looking for double (“triple”) pulsation

If unable to visualise:

o

Sitting patient upwards more makes higher JVP visible

o

Laying patient down further makes lower JVP visible

o Laying patient down further makes lower JVP visible  External jugular – if it varies

External jugular if it varies with respiration and has double pulsation can be used as surrogate for JVP

Radial pulse corresponds to x descent

Estimation of Central Venous Pressure (CVP)

JVP height measured with ruler placed vertically perpendicular to the Angle of Louis.

o Second straight object placed horizontal to maximal height of JVP so that in crosses vertical ruler at 90°

CVP = JVP +5cm (Angle of Louis ~5cm above right atrium).

Upper limits of normal:

o

JVP 3-4cm

o

CVP 9cm

Accuracy of JVP for predicting CVP (+LR 3.1)

Utility of JVP on Inspection Predicting post-op pulmonary oedema (+LR 11.3) Detecting CVP >12cm (+LR 10.4; -LR 0.1) Detecting CVP >8cm (+LR 9.7; -LR 0.3) Predicting post-op MI or cardiac death (+LR 9.4) Detecting CVP ≤5cm (+LR 8.4; -LR 0.1) Detecting LVEF (+LR 6.3) Detecting LV diastolic filling pressure (+LR 3.9)

Abdominojugular Reflux (AJR)

Once peak JVP waveform located can perform this manoeuvre

Abdominojugular Reflux (AJR)  Once peak JVP waveform located can perform this manoeuvre UNIVERSITY OF MANITOBA

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Apply firm 35mmHg pressure to central abdomen (location on abdomen not important)

Initially JVP will be displaced upwards

o

Normally it will return to original height in <10s

o

If remains elevated >4cm or >10s it is a (+) response

Indicated RV failure or RV compliance

(+) AJR in predicting CVP (+LR 4.4)

o Predicting LV diastolic pressure (+LR 8.4; -LR 0.1)

Kussmaul’s Sign

Paradoxical in JVP during inspiration (instead of normal )

Occurs when RV filling limited & unable to accommodate the venous return caused by intra-thoracic pressure during inspiration

o RVF or constrictive pericarditis

Distinguishing JVP from Carotid

Feature

JVP

Carotid

Filling

Fills from

Fills from

above

below

Pulsation

Diffuse,

Localised &

complex,

single

double/triple

pulsation

pulsation

Palpable

Not palpable

Palpable

Obliteration

Obliterates

Only

with

obliterates

Pressure just

with extreme

Above

pressure

Clavicle

Variation

Changes with

No change

with Posture

posture

with posture

Respiratory

With

No change

Variation

inspiration

with

 

respiratory

cycle

Change with

with

No change in height of carotid

Abdominal

abdominal

Pressure

pressure

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Valvular Diseases Approach to a Murmur

Jonathan Laxton (2013)

Classification of Murmurs

Systolic Murmurs

Early systolic

o

Acute MR apex or LUSB

o

Low-pressure TR LLSB

o

Small VSD LLSB

Mid-systolic

o

PS LUSB

o

ASD LUSB

o

HCMP LLSB

o

AS RUSB, LLSB or apex

o

Papillary muscle dysfunction apex

Late systolic

o

MVP apex

o

Papillary muscle dysfunction apex

Holosystolic

o

MR apex

o

VSD LLSB

o

High pressure TR LLSB, apex

o

AS RUSB, LLSB or apex

Diastolic Murmurs

Early diastolic murmur

o

AR LLSB

o

High pressure PR LUSB

Mid-diastolic murmur

o Low pressure PR LUSB

Mid-diastolic, pre-systolic or both

o

MS apex

o

TS LLSB

Continuous Murmur

PDA LUSB

AV fistula over fistula

Venous hum over head of scapula

Mammary soufflé between breast & sternum

Aortic coarctation mid-scapula

Murmur Grading

Grade 1 so faint can only be heard with special effort

Grade 2 readily recognised when stethoscope placed on chest

Grade 3 very loud but no associated thrill

Grade 4 very loud & associated with thrill

Grade 5 audible when only edge of stethoscope in contact with chest

Grade 6 audible when stethoscope just lifted off chest.

Manoeuvres & Mechanisms

Normal inspiration

o Patient breathes normally in & out

Manoeuvres Affecting Venous Return

Valsalva manoeuvre (venous return)

o

Patient exhales against closed glottis for up to 20s

o

Murmur changes at end of strain phase

Squatting-to-standing (venous return)

o

Patient squats for at least 30s & then rapidly stands up

o

Murmur changes immediately after standing

Standing-to-squatting (venous return)

o

Patient squats rapidly from standing position while breathing normally (avoid Valsalva)

o

Murmur changes immediately after squatting

Passive leg elevation

o

Patient’s legs passively elevated to 45° while patient supine

o

Murmur changes 15-20s after leg elevation

Manoeuvres Affecting Systemic Vascular Resistance

Isometric handgrip exercise (afterload)

o

Patient uses one hand to squeeze examiner’s index & middle finger together tightly

o

Murmur changes after ~1min after maximal contraction

Transient arterial occlusion (afterload)

o

Examiner places Bp cuff around both upper arms & inflates them above systolic pressure

o

Murmur changes 20s after cuff inflation

 

HOCM

MVP

AS

MR

Valsalva

louder

longer

softer

softer

strain

phase (

preload)

Squatting

softer

shorter

louder

louder

or leg

raise (

preload)

Hand

softer

shorter

softer

louder

grip (

afterload)

preload) Hand softer shorter softer louder grip ( ↑ afterload) UNIVERSITY OF MANITOBA 10

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Right Heart Murmurs

Vital Signs

Kapil Bhagirath (Original)

Low Bp ± low pulse pressure if cardiac output from associated RHF

Tachycardia with irregularly irregular rhythm AF associated with TR & TS

Inspection (JVP)

Tricuspid Stenosis (TS)

↑ JVP with wave abnormalities:

o

Giant a wave (atrial contraction against stenotic valve)

o

Slow y descent (atria takes longer to empty due to stenotic valve)

Tricuspid Regurgitation (TR)

↑ JVP with wave abnormalities:

o

Prominent v wave (regurgitation from ventricle during atrial filling)

o

Loss of x descent (severe TR with markedly ↓ CO)

o

Prominent cv wave with rapid y descent

Pulmonary Stenosis (PS)

Giant a wave (RA hypertrophy impedes atrial kick)

Pulmonary Regurgitation (PR)

JVP findings of TR (2° to dilation of RV)

Praecordial Examination

Inspection

Prominent RV pulsation along left parasternal border (TR, PS, PR)

o

Only if PR 2° to PHT

o

Argues for TR (+LR 12.5)

Right ventricular rock systolic outward movement left parasternal area & retraction at PMI for TR (+LR 31.4)

Previous sternotomy scar

Palpation

Feel RV heave at left parasternal border.

Thrill over pulmonary area (PS)

Auscultation

Tricuspid Stenosis (TS)

Diastolic murmur most audible at left sternal edge & xiphoid process

o

↑ Intensity with inspiration

o

Similar quality to MS but different location

o

↓ Intensity with expiration & strain phase of Valsalva manoeuvre

Occasionally able to hear opening snap (OS) after P 2 .

Tricuspid Regurgitation (TR)

Holosystolic murmur loudest at LLSB

o

↑ Intensity with inspiration

o

↓ Intensity with expiration & strain phase of Valsalva manoeuvre

o

Similar quality to MR but different location

Pulmonary Stenosis (PS)

Harsh systolic crescendo-decrescendo murmur at LUSB (pulmonic area)

Severe PS often associated with TR murmur

Right-sided S 4 (LLSB instead of apex)

Wide physiological splitting of S 2

o Correlates to severity of PS (r = 0.87; p< .001)

DDx Widely Split S2 P 2 Delayed Electrical delay of RV systole (RBBB, LV paced or ectopic beats) Prolongation of RV systole (PS, acute cor pulmonale) ↑ Hangout interval (dilatation of pulmonary artery) A 2 Early Shortening of LV systole (MR)

Pulmonary Regurgitation (PR)

Decrescendo diastolic murmur at left sternal border.

o

High-pitched

o

↑ Intensity with inspiration

o

Known as Graham-Steel murmur

Accentuated P 2 due to associated PHT.

Peripheral Examination

Peripheral signs of RHF:

o

Hepatomegaly

o

Ascites

o

Peripheral oedema (usually anasarca)

Pulsatile liver TR, TS & PS

o Detecting significant TR (+LR

6.5)

Long-standing hepatomegaly can result in “cardiac cirrhosis” with signs of chronic liver disease

Severe PS

SEM peaking late in systole

Absence of ejection click (or when PS infundibular)

Presence of right-sided S 3

INTERNAL MEDICINE OSCE BOOK

2014 EDITION

Aortic Regurgitation (AR)

Aetiology

Stephen Goulet (Original) Ernest Inegbu (2012)

Valvular disease:

o

Rheumatic heart disease

o

Endocarditis (bacterial or marantic)

o

Bicuspid aortic valve

o

Myxomatous degeneration

o

Connective tissue disease RA, SLE, ankylosing spondylitis

o

Marfan’s syndrome

o

Fan/Phen

Aortic root disease:

o

HTNDe

o

Dissection or thoracic aortic aneurysm

o

Aortitis 3° syphilis, reactive arthritis, GCA, Takayasu’s arteritis, ankylosing spondylitis, IBD

o

Connective tissue disease Ehlers-Danlos syndrome, osteogenesis imperfecta

Vital Signs

Wide pulse pressure - >50mmHg or >50% systolic Bp

Hands & Upper Extremities

Waterhammer or Corrigan’s pulse – obliterate radial pulse while patient supine

o

Elevate patient arm until 90° perpendicular to body

o

In AR pulse will become palpable again when arm raised despite continuous pressure

Quincke’s sign – capillary pulsation in nail beds after pressure applied to distal aspect of nail.

Head & Neck

DeMusset’s sign – head bob occurring with each heartbeat.

Becker’s sign – visible pulsation of retinal arterioles

Müller’s sign – systolic pulsation of uvula

Carotid pulse brisk upstroke, bounding character

Praecordial Examination

Inspection

Apex pulsation displaced laterally/inferiorly

Previous sternotomy scar

Palpation

Apex (PMI) displaced laterally & inferiorly & is hyperdynamic

o

Combined eccentric LVH with forceful systolic function

o

PMI normal or not palpable argues against moderate-to- severe AR (-LR 0.1)

Prominent pulsation (±thrill) at sternal notch due to concurrent dilatation of ascending thoracic aorta.

Auscultation

Soft S 1 (early closure of MV)

o Strongly suggests acute MR

DDx Soft S1 Immobility of MV Calcific mitral stenosis Lack of Apposition of MV Leaflets Rheumatic MR Presystolic Semiclosure of AV Valves Long PR interval Acute AR Significant AS Dilated CMP Conduction Anomaly LBBB

Variable S 2 (soft, absent or single)

o A 2 often soft or absent while P 2 often normal (but may be obscured by diastolic murmur)

Systolic ejection sound (abrupt aortic distention from large stroke volume)

S 3 if LV function severely depressed

Diastolic murmur:

o

High-pitched, blowing, decrescendo & early murmur

o

Best heard with patient upright in end-expiration

o

LUSB 2 nd -3 rd ICS aortic root disease

o

RUSB 2 nd -3 rd ICS aortic root disease

o

Intensity may correlate with severity (grade 3 murmur distinguishes severe from less severe AR) (+LR 4.5)

o

Mild AR murmur only in diastole & blowing

o

Moderate AR murmur extends through more of diastole, may become holodiastolic & often rougher in quality

o

Severe AR with ventricular decompensation murmur often soft & absent (also occurs with acute AR due to loss of gradient from LVEDP)

often soft & absent (also occurs with acute AR due to loss of gradient from ↑

INTERNAL MEDICINE OSCE BOOK

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o

Presence of diastolic murmur heard by cardiologist predicts >mild AR (+LR 8.8-32)

o

Absence of diastolic murmur to cardiologist suggests less than mild AR (-LR 0.2-0.3)

o

ESRD may be transient diastolic murmur that disappears post-HD

may be transient diastolic murmur that disappears post-HD  Systolic murmur – often heard in many

Systolic murmur often heard in many patients

o SEM, right 2 nd ICS (often thought to be high flow murmur)

Austin-Flint murmur

o Low-pitched mid-to-late diastolic rumble at apex (best heard in LLD)

Causes of Apical Diastolic Rumble MS Austin-Flint Murmur (AR) Mitral annular calcification Atrial myxoma VSD

o Ante-grade turbulent flow from LA competing with retrograde regurgitant AV flow

Austin-Flint Murmur Mitral Stenosis AF Loud S 1 No S 3 Opening snap (OS) Louder with amyl nitrate inhalation Austin-Flint Murmur NSR Faint S 1 (premature closure of MV) S 3 present No opening snap (OS) Softer with amyl nitrate inhalation

Abdomen

Pistol-shot sound heard over femoral artery (often very severe AR)

Hill’s sign – popliteal cuff systolic pressure exceeding brachial artery pressure >60mmHg

o

Performed with patient supine

o

Indicated moderate or greater AR (+LR 8.2; -LR 0.2)

Note

Many of the peripheral signs are manifestations of hyperdynamic circulation & not specific to AR.

Other causes SV:

o

Sympathetic hyperactivity

o

Severe anaemia

o

Fever

o

Pregnancy

o

Thyrotoxicosis

o

Large AV fistula

o

PDA Severe bradycardia

Severity of AR

Collapsing pulse

Wide pulse pressure

o

Pulse pressure ≥80mmHg (+LR

10.9)

o

Pulse pressure <60mmHg (-LR

0.3)

Long decrescendo diastolic murmur

LV S 3 (+LR 5.9)

Soft A 2

Austin-Flint murmur

Signs of LV failure

Hill’s test

o

<40mmHg (+LR 0.3)

o

≥60mmHg (+LR 17.3)

Diastolic Bp ≤50mmHg (+LR 19.3)

Murmur grade ≥3 (+LR 8.2)

Sustained or displaced apex (-LR 0.1)

Surgical Indications

Class I surgical indications (AHA/ACC)

Rosenbach’s sign – systolic pulsation of the liver

o

Symptomatic chronic severe AR

Gerhard’s sign – systolic pulsation of the spleen

o

Development of symptoms

Asymptomatic with LVEF

Lower Extremities

o

during exercise test

Duroziez’s sign – systolic + diastolic bruit

50%

heard when femoral artery partially compressed with rim of stethoscope

o

Severe AR undergoing CABG

 

o

Diastolic bruit louder when distal rim of stethoscope compressed

or other cardiac surgery

o

Diastolic bruit softer when proximal rim compressed

o

If opposite more likely another high flow state other than AR

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Pulmonary Regurgitation (PR)

Aetiology

Stephen Goulet (Original) Ernest Inegbu (2012)

Dilatation of pulmonary annulus

o

Pulmonary hypertension (PHT)

o

PA dilation

o

Connective tissue disease

Infective endocarditis

General Appearance

Cyanosis (PHT)

Vital Signs

Hypoxaemia (PHT)

Low Bp ± low pulse pressure (cardiac output from RHF)

Head & Neck

Elevated JVP ± Kussmaul’s sign (RHF)

Often findings of TR (2° dilatation of RV)

Praecordial Examination

Inspection

Visible RV heave

Previous sternotomy scar

Palpation

Hyperdynamic RV (left parasternal area)

o Place palm of hand flat on chest

Palpable P 2 LUSB 2 nd ICS (PHT) or thrill (rare)

Auscultation

Normal S 1

Loud P 2 (PHT) ± abnormal splitting of S 2 (RV volume)

RV S 3 or S 4

Early diastolic murmur

o

Low-pitched decrescendo

o

Loudest LUSB 2 nd ICS ± radiation to 3 rd & 4 th ICS

o

Manoeuvres quiet inspiration or sustained abdominal pressure

– quiet inspiration or sustained abdominal pressure  Graham-Steell murmur (PA pressure >60mmHg) o

Graham-Steell murmur (PA pressure

>60mmHg)

o

High-pitched blowing decrescendo diastolic murmur at LUSB 2 nd -4 th ICS + findings of severe PHT

o

Distinguish from AR murmur no peripheral findings of AR, signs of TR

Right-sided Austin-Flint murmur

Abdomen

Hepatomegaly

Ascites

Pulsatile liver (TR)

Lower Extremities

Peripheral oedema

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Mitral Stenosis (MS)

Aetiology

Stephen Goulet (Original) Ernest Inegbu (2012)

Rheumatic Heart Disease (most common worldwide)

SLE

Amyloidosis

Carcinoid

Thrombus

Infective endocarditis

LA myxoma (functional MV obstruction)

Mitral annular calcification

General Appearance

Respiratory distress (pulmonary venous congestion with pulmonary oedema)

Mitral facies pink/purple patches on face (peripheral vasoconstriction due to ↓↓ cardiac output from MS)

Vital Signs

due to ↓↓ cardiac output from MS) Vital Signs  Tachycardia, irregularly irregular (AF)  ↓

Tachycardia, irregularly irregular (AF)

Bp (cardiac output)

Hypoxaemia (pulmonary venous congestion/PHT)

Praecordial Examination

Inspection

Usually normal

Previous sternotomy scar

Palpation

Normal PMI

RV heave ± palpable P 2 (PHT)

Apical thrill

Auscultation

S 1 loud with milder disease (LA pressure keeps stenotic leaflets apart)

o

Quieter with more severe disease (stenotic valves leaflets closer together at systole)

o

Variable intensity S 1 with AF

DDx of Loud S1 AV Valve Obstruction Mitral stenosis (early) LA or RA myxoma Tricuspid stenosis

Increased Transvalvular PDA Flow

VSD ASD Forceful Ventricular Systole Hyperkinetic heart syndrome Tachycardia (exercise) MVP Short PR Interval Pre-excitation syndrome

Palpable P 2 LUSB 2 nd ICS very brief impulse corresponding to S 2

o

(+) P 2 with MS suggests mean PAP >50mmHg (+LR 3.6)

o

Absence of palpable P 2 argues strongly against associated PHT (-LR 0.05)

Opening snap (OS)

o

Early mid-diastolic sound loudest at apex

o

MV leaflets opening & snapping due to high LA pressure with MV leaflet tip tethered together

o

Earlier in diastole with more severe MS (time between S 2 & OS)

P2 versus OS Suggests P 2 Louder with inspiration Sitting standing has no effect on A 2 -P 2 interval Suggests OS Softer with inspiration Sitting standing lengthens A 2 -OS interval (preload & LA pressure)

Murmur

o

Low-pitched diastolic rumble (± presystolic accentuation) loudest at apex

o

In LLD position

o

Mild MS late diastole

o

Moderate MS early diastolic decrescendo murmur ± presystolic accentuation

o

Severe MS soft holodiastolic murmur (may be absent)

Severe MS – soft holodiastolic murmur (may be absent) Severity of MS  Valve area <1cm

Severity of MS

Valve area <1cm 2

o

Small pulse pressure (immobile valve cusps)

o

Early opening snap (LAP)

o

Long diastolic murmur (persists as long as gradient present)

o

Diastolic thrill at apex

o

Signs of PHT

(persists as long as gradient present) o Diastolic thrill at apex o Signs of PHT UNIVERSITY

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Investigations

Chest x-ray

o

Signs of LAE (see box below)

o

Mitral annular calcification (elderly)

o

Enlargement of main pulmonary artery (PHT)

o

Signs of HF

of main pulmonary artery (PHT) o Signs of HF CXR Findings of LAE Posterior displacement of

CXR Findings of LAE Posterior displacement of oesophagus (lateral CXR) Loss or aortic notch (PA) “Double hump” on right heart silhouette (PA) Splaying of the carina (PA)

EKG

o

P-mitrale from LAE

o

Severe signs of PHT (RVH)

P-mitrale from LAE o Severe – signs of PHT (RVH) Surgical Indications  Class I surgical

Surgical Indications

Class I surgical indications (AHA/ACC)

o

Symptomatic with NYHA III-IV symptoms if percutaneous mitral balloon valvotomy (PMBV) not available; PMBV contraindicated due to moderate to severe MR or LA thrombus that persists despite anticoagulation

o

Symptomatic patients with moderate to severe MR

INTERNAL MEDICINE OSCE BOOK

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Tricuspid Stenosis (TS)

Aetiology

Stephen Goulet (Original) Ernest Inegbu (2012)

Rheumatic heart disease (most common)

o Often associated with aortic & mitral valvular disease

Endocarditis

Carcinoid syndrome

Vital Signs

Irregularly irregular tachycardia (AF)

Hypotension (RHF)

Head & Neck

JVP

o

Prominent a wave

o

↓↓ y descent

o

Kussmaul’s sign (RHF)

o

Cv wave if associated TR

Praecordial Examination

Inspection

RV heave (only if concomitant left-sided disease)

Previous sternotomy scar

Palpation

RV heave (only if concomitant left-sided disease)

May have thrill at LLSB

Auscultation

Normal S 1 (may be loud early or soft late)

Normal S 2 ± opening snap (OS)

No gallop

Murmur low-pitched diastolic rumble loudest at LLSB, no radiation

o Respiratory variation

Respiratory

Lung field clear to auscultation (right- sided obstruction)

Extremities

Pedal oedema

Track marks (IVDU-associated right-sided IE)

Other peripheral signs of IE

Tricuspid Regurgitation (TR)

Aetiology

Jonathan Laxton (2014)

Functional RV failure

Rheumatic heart disease (associated with MV disease)

Endocarditis (more common with IVDU)

RV papillary muscle infarction

Trauma steering wheel injury to sternum)

Ebstein’s anomaly

TV prolapse

Head & Neck

JVP

o

Large v wave (can combine to cv wave)

o

If associated with RHF

Praecordial Examination

Palpation

RV heave (parasternal impulse)

Auscultation

Pansystolic murmur loudest at LLSB, on inspiration

Respiratory

Signs of pleural effusion

Abdomen

Pulsatile, large & tender liver

o Right nipple may “dance” in time with pulse

Ascites

Lower Extremities

Peripheral pitting oedema

Dilated & pulsatile veins.

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Mitral Regurgitation (MR)

Aetiology

Masud Ali (Original)

Valve leaflets

o

Myxomatous degeneration (see MVP)

o

Rheumatic heart disease

o

Infective endocarditis

o

Congenital heart disease

o

Connective tissue disease – Marfan’s, RA, ankylosing spondylitis

Valve annulus dilatation (2° to LV dilatation)

Rupture of chordae tendinae

o

AMI

o

Infective endocarditis

o

Trauma

Papillary muscle dysfunction

o

Ischaemia

o

Hypertrophic & ischaemic CMP

o

LV aneurysm

General Appearance

Respiratory distress

Pale, febrile, generally ill (IE)

Posture of ankylosing spondylitis

Features of Marfan’s syndrome

Features of RA

Vital Signs

Normal pulse, sharp upstroke

o Irregularly irregular tachycardia (AF)

Bp normal or from low cardiac output.

Tachypnoea if associated HF (± hypoxaemia)

Head & Neck

Normal JVP (only if advanced associated with PHT/RHF)

o Loss of a wave if AF

Carotid pulse sharp upstroke

Praecordial Examination

Inspection

Previous sternotomy scar

Palpation

Displaced PMI (down & towards mid- axillary line)

o

Diffuse place 3 fingers over PMI, lift middle finger off chest & if PMI still felt by outer 2 fingers it is likely diffuse

o

Palpable S 3

Systolic thrill at apex (MV area)

Parasternal impulse LLSB (LA enlargement)

o Correlates with severity of MR (r = 0.93; p<.01)

Auscultation

S 1 soft, variable if AF

S 2 widely split (early A 2 closure)

o

Loud P 2 if associated PHT

o

Loud S 2 argues for MR (+LR

4.7)

S 3 common (“Montréal” or lub bu dup)

Murmur holosystolic ± extension beyond S 2

o

High-pitched (diaphragm)

o

Maximal intensity at apex radiates to axilla (or back, depending on direction of jet)

o

Broad apical pattern argues for MR (+LR 6.8)

jet) o Broad apical pattern argues for MR (+LR 6.8)  Manoeuvres: o ↑ Intensity with

Manoeuvres:

o

Intensity with afterload (handgrip) (+LR 5.8; -LR 0.3)

o

↑ Intensity with ↑ preload (squatting, leg elevation)

o

↓ Intensity with ↓ preload (Valsalva manoeuvre, standing from seated)

o

↑ Intensity with transient arterial occlusion Bp cuff inflated to >20mmHg over systolic pressure on both proximal arms (+LR 48.7; -LR 0.2)

Severe Chronic MR

Small volume pulse

Enlarged LV

Loud S 3

Soft S 1

Early A 2 (rapid LV decompression into LA AV closes early)

Signs of PHT

Signs of LVF

Murmur grade ≥3 (+LR 4.4; -LR 0.2)

Acute MR

Pulmonary oedema & CV collapse

Systolic apical thrill & loud apical systolic murmur, S 4 argues for acute

Chordae tendinae rupture radiates to axilla & back

Posterior leaflet rupture radiates to cardiac base & carotids

Surgical Indications

Class I indications (AHA/ACC)

o Symptomatic acute MR

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o

Severe symptomatic chronic MR (NYHA II-IV)

o

Asymptomatic chronic severe MR with LVEF 30-60% and/or LVESD ≥40mm

o

Mitral repair preferred over replacement whenever possible

INTERNAL MEDICINE OSCE BOOK

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Mitral Valve Prolapse (MVP)

Aetiology

Masud Ali (Original)

Myxomatous degeneration of mitral valve (most common)

Associated conditions:

o

Marfan’s syndrome

o

Ehlers-Danlos syndrome

o

Osteogenesis imperfecta

o

Hypertrophic CMP

General Appearance

Usually normal

Mmarfanoid features in some:

o Arachnodactyly thumbs stick out of ulnar side when clenched in fist

– thumbs stick out of ulnar side when clenched in fist o Pectus carinatum more specific

o

Pectus carinatum more specific (pectus excavatum or chest asymmetry less specific)

o

Arm span greater than height

o

Kyphoscoliosis

o

Enophthalmos, down-slanting palpebral fissures, malar hypoplasia, retrognathia

o

Ectopic lentis

Vitals Signs

Usually normal

Head & Neck

JVP usually normal

Normal carotid contour

Praecordial Examination

Auscultation

Normal S 1 & S 2 with normal split

o Can have a loud S 1 due to delayed MV leaflet closure

High-pitched mid-systolic click

o Can be heart over TV either from TVP or transmitted from MV

Murmur late systolic murmur starting after click

o

Murmur lengthens as regurgitation becomes more severe

o

Anterior leaflet prolapse radiates to axilla & upper back

o

Posterior leaflet prolapse radiates to LSB & aortic area

Manoeuvres:

o

Preload (Valsalva, standing seated) earlier systolic click (closer to S 1 ) & longer/louder murmur

o

Preload (squatting, leg raise when supine) later systolic click (further from S 1 ) & shorter/softer murmur

when supine) – later systolic click (further from S 1 ) & shorter/softer murmur UNIVERSITY OF

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Aortic Stenosis (AS)

Aetiology

Renelle Myers (Original) Ernest Inegbu (2012)

Congenital bicuspid & unicuspid valves

Rheumatic heart disease (almost always associated with MV disease)