Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

CARDIOLOG Y OSCE S T ATION RAHUL AGGARWAL KING’S COLLEGE LONDONTTHE CARDIO ST A TION CARDIOVASCULAR ECG SPOT DIAGNOSIS EXAMHOW CONFIDENT On a scale of 1-10, how well do you think you would ARE YOU? do at a cardiovascular OSCE station?TIPS FOR THE OSCE • Read the instructions carefully • Did you wash them? • Always perform WIPE • W- Wash hands, I- Introduce yourself, P- Patient details, E- Explain the examination • Fake it till you make it • Manners cost nothing • Keep calm and carry onCARDIAC EXAM - INTR O WIPE Consent Pain Position patient appropriately (lying down at 45 degrees) Expose patient adequatelyCARDIAC EXAM - GENERAL INSPECTION • Around the bed- oxygen, IV drips, ECG •Patient- comfortable, alert, bremachine, mobility aids, pillows, vital sign pallor, cyanosis, scars, oedema chart, prescriptions & medicationsCARDIAC EXAM- Back of hands HANDS Front of hands Clubbing Temperature Cap refillCARDIAC EXAM - HANDS • Perfusion • Nails • Palms Xanthomata Assessing Assess Clubbing temperature Capillary Refill Splinter Osler nodes Hemorrhages Peripheral Cyanosis Tar Staining Janeway lesionsCARDIAC EXAM - ARMS • Inspect • Radial pulse (Rate & Rhythm) • Radio-radial delay • Collapsing Pulse • Blood pressureCARDIAC EXAM- HEAD & NECK General inspection of face Look at their eyes Ask patient to pull down eyelids Ask patient to open their mouth and stick their tongue out Raise tongue to roof of mouth Ask patient to turn neck away from you (JVP) Auscultate & palpate carotid pulse CARDIAC EXAM - HEAD & NECK Mouth Neck Eyes Central Cyanosis Conjunctival Pallor Palpate Carotid Pulse Corneal Arcus Stomatitis Raised JVP Poor dental Xanthelasma hygiene CARDIAC EXAM - CHEST •InspectCARDIAC EXAM - CHEST • Palpation- apex beat, heaves/thrills • Auscultation- palpate carotid pulse & auscultate all heart valves (never put on top of breast)CARDIAC EXAM - CHEST • Accentuation maneuvers- Always ask patient to Normal breathe out and hold Pathology Patient position Stethoscope Where to position auscultate? AS Aortic Stenosis 45 degrees lying Diaphragm Carotid artery down (normal) (radiates from aortic area) Aortic RegurgitatiSit patient forwardDiaphragm Aortic area AR Mitral Stenosis Roll patient onto lBell Mitral area side Mitral RegurgitatiRoll patient onto lDiaphragm Mitral area (radiates MS side to axilla so auscultate into this region) MR CARDIAC EXAM - CONCL USION •Auscultate lung bases- Coarse crackles can be a sign of LVF •Palpate sacrum (lower back)-oedema •Palpate ankles- oedema can be a sign of RVF •Thank patient & ask if they would like help getting dressed Begin by stating who you examined PRESENTING AN EXAMINATION What did you see on general inspection? Was there any peripheral stigmata of cardiovascular disease? Describe his pulse and JVP Were there any scars? Where was the patient's apex beat? Describe the heart sounds Summarise with key findings What other tests would you like to do? I performed a Cardiovascular examination of Mr Morgan Freeman, a 84 year old man. PRESENTING AN On general inspection, he was comfortable sitting upright on the bed and seemed alert and orientated. EXAMINATION There were no signs of any peripheral stigmata of cardiovascular disease. The pulse was 80, regular and had a strong volume. His JVP was not elevated On closer inspection of his chest, there were no scars to suggest previous surgeries His apex beat was not displaced There were normal heart sounds with no added sounds In summary, this was a normal cardiovascular examination. To complete my examination, I would like to take a full cardiac history, conduct a 12 lead ECG, and perform a peripheral vascular exam.CARDIO EXAM OSCESTOP CARDIOVASCULAR GEEKY MEDICS SIMPLE OSCE EXAM CARDIO EXAM CARDIO EXAMA GUIDE TO ECG INTERPRTATION ECG INTERPRET ATION 1. Check patient– Name, DOB, Hospital No 2. Check date and timECG was taken 3. Check calibration (usually 25mm/sec) 4. Ra= 300/No. of boxes between ECGINTERPRE T A TION QRS OR No. of QRS x6 5. Rhythm- are QRS complexes regularly or irregularly spaced 6. Axis- Look at leads I and aVF • Normal= I and aVF +ve • Left Axis Deviation= I +ve, aVF - ve • Right Axis Deviation= I-ve, aVF +ve 7. P waveAre they present before each QRS? 8. QRS complex- Narrow (<120ms or 3 small boxes) - sinus, atria, supraventricular Broad (>120ms or 3 small boxes)- Likely ventricular origin ECG INTERPRET ATION 9. P-QRS-T Relationship • PR Interval- Is it increased (> 5 small boxes) • ST elevation • ST Depression • T wave Inversion (Normal inaVR and V1)COMMON ECG FINDINGSSTEMI ST elevation is seen in leads V1-V4 Most commonly seen in these leads This is an anterior MIST ELEVATIONLEFT BUNDLE BRANCH BLOCK • QRS >120ms • Downward deflection in V1 lead • Anterior MINSTEMI OR UNST ABLE ANGIN A •ST Depression (V1- V3) •T wave inversion (V1-V3) •How do we differentiate between NSTEMI and unstable angina? •TROPONINPERICARDITIS • Widespread ST elevation • Possible ST depression in aVRFIRST DEGREE HEAR T BLOCK •Increased PR interval > 5 small boxes SECOND DEGREE- MOBITZ TYPE 1 • Constantly increasing PR interval • Dropped beat due to non conducted P waveSECOND DEGREE- MOBITZ TYPE II • Intermittent non conducted P waves • No prolonging of PR interval • Usually in ratio (2:1, 3:1, 4:1)COMPLE TE (THIRD DEGREE) HB •Bradycardia •AV dissociation •In this example there is a P wave every 3 boxes •There is a QRS complex every 10 boxesATRIAL FIBRILLATION • Very fast atrial rate • Non smoothness in P wave area • QRS complexes are irregularATRIAL FLUTTER • Sawtooth in P region • QRS are regularVENTRICULAR T ACHYCARDIA • Wide QRS complex • Originates at ventricles • Amplitude remains constant • No P waves seenVENTRICULAR FIBRILLA TION •Wide QRS Complex •Ventricular origin •Irregular amplitudeSPOT DIAGNOSIS Role Medical Student Setting Emergency Department Patient Mr Morgan Freeman, a 78 y/o male who has a has presented with chest pain Student Task Please perform a full cardiovascular examination on this patient At 6 minutes, the examiner will stop you, ask you to summarise your findingsSPOT DIAGNOSIS • 78 year old man presents with chest pain and breathlessness • Sharp left-sided • Sudden onset- began 2 hours ago • No signs of peripheral cardiovascular disease • Heart sounds- I+II+0 • PMH of Prostatic Lung Cancer PULMONARY EMBOLISM SPOT DIAGNOSIS • 54 year old man presents with chest pain and breathlessness • Central chest pain radiating to left shoulder • PMH- Hypertension • On examination, he is haemodynamically stable • Heart sounds- I+II+0 • Troponin has been taken but results haven’t been received yet Lateral ST-elevation Myocardial Infarction (STEMI) SPOT DIAGNOSIS • 31 year old man presents with chest pain • 3 day history of progressive severe sharp chest pain. Pain is worse when lying down • Febrile and friction rub • Heart sounds- I+II+0 • Troponin slightly raised PERICARDITISSPOT DIAGNOSIS • 29- year old woman presents with chest pain and breathlessness • 2 hour duration of tearing chest pain 3/10 intensity, radiates to back of the neck • No signs of peripheral cardiovascular disease- calves are non tender • Heart sounds- I+II+0 • Describes a history of chronic fatigue and restlessness ANXIETY • Troponin- negativeSUMMAR Y OSCE TIPCAREXAMASCULAR SPOT DIAGNOSISECGOSCE RESOUR CES BOOKS WEBSITESHOW CONFIDENT On a scale of 1-10, how well do you think you would ARE YOU? do at a cardiovascular OSCE station?THANK YOU! Please fill out the feedback using the QR code or the link the chat!