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Cardo Hx nd Exam (2437808c@student.gla.ac.uk)Areas to cover Spot diagnosis – interactive Cardio history Cardio examination on or type! questions – mics Key conditions and findings Cheat sheet summariesCardio History Family Introduction History Drug Presenting History Complaint Family History History of ICE Presenting Complaint Social History Systemic Inquiry Summary Introduction Wash hands and don PPE (you Introduce yourself, Establish consent will be told before OSCE what confirm patient name the PPE requirements are) and DOB Easy to forget in the moment but worth 2 marks!! Presenting Complaint • Common cardio presenting complaints: – Chest pain – Palpitations – Dyspnoea (shortness of breath) – Ankle swelling – Dizziness (syncope) – Intermittent claudication Chest pain history – Focused questions Full name, DOB, consent History of presenting complaint Past medical history Systems review Site – where is the pain • Palpitation Onset – when did it start Any relevant past history • Shortness of breath Character – History of hypertension / diabetes / Radiation – cholesterol • Calf swelling Associated symptoms – Any previous events like this? • Nausea / vomiting Timing – History of calf swelling • Sweating Exacerbating and relieving factors – Any history of surgeries or procedures • Fever performed? Severity – • Unexplained weight loss • Night sweats Social / Family and drug history • Dizziness • Cough Any family history of cardiovascular disease? • GI / GU / Neuro screening Smoking / alcohol / recreational drug use Allergies Housing and mobility Condition History Condition History Acute coronary syndrome • Central crushing chest pain GORD • Burning epigastric pain • Radiates to arm and jaw • Worse after meal • SOB • Nausea, sweating • CV risk factors Aortic dissection • Tearing chest pain Peptic ulcer disease • Burning epigastric pain • Radiates to back • Can improve or worsen after • Sudden onset meals • History of HTN • History of NSAID use Acute pericarditis • Pleuritic chest pain Pneumonia • Fever • Relieved by sitting forward • Shortness of breath • Fever • Productive cough • History of illness • Pleuritic chest pain Pulmonary embolism • Pleuritic sharp chest pain Costochondritis • Sharp localised chest pain • SOB • Tenderness at sternal edges • Red swollen leg – DVT • Worse with coughing and • VTE risk factors; OC, travel movement Pneumothorax • Pleuritic chest pain Anxiety / panic attack • Tight chest pain • SOB • Shortness of breath • Young thin male • Sweating • Hyperventilation • Recurrent triggering event Palpitations history – Focused questions Full name, DOB, consent History of presenting complaint Past medical history Systems review What do you mean by palpitation? Any relevant past history Is this new or recurrent? • Chest pain Do you feel it right now? History of hypertension / diabetes / • Shortness of breath Can you tap out the rhythm of it? cholesterol • Calf swelling Do you feel like your heart skips a beat? Any previous events like this? • Nausea / vomiting What happens before it starts? Any history of thyroid disease What happens after it? Any history of mood disorders • Sweating Any obvious triggers? Any history of surgeries or procedures • Fever Any changes to mood or anxiety performed? • Unexplained weight loss Any issues with sleep • Night sweats • Dizziness Social / Family and drug history Causes: • Cough • AF • GI / GU / Neuro screening Any family history of cardiovascular disease? • Tachycardia (SVT / VT) Smoking / alcohol / recreational drug use • Thryotoxicosis Allergies • Excess caffeine intake Housing and mobility • Hypoglycaemia Systemic Inquiry ASK THE RED FLAGS!!! Fevers Night Weight Cough GI GU Neuro sweats loss Other tips • Past medical history à don’t forget to ask about surgeries • Drug history à prescribed and over the counter . Ask about allergies and what type of reaction • Family history à can ask cardio specific ones too like “any history of heart disease in the family” • Social historyà smoking, alcohol but also diet and exercise OSCE questions • Know the management for common cardio conditions e.g. ACS, angina, PE, heart failure • Interpretation of chest X-rays (join our next session) • ECG interpretation (join our next session) • What next investigations would you perform à Always less invasive to more invasive i.e. bloods, imaging, procedures and special tests • 3 modifying and 3 non-modifiable risk factors for [condition] ABCDE approach Acute Coronary MONA for initial management M – IV Morphine Syndrome O – Oxygen Management N – GTN spray A – Aspirinà If PE likely then immediate CTPA Pulmonary Embolism Anticoagulant - DOAC IV thrombolysis for massive PE Management Drugs that reduce mortality: • ACE inhibitor Heart Failure • Beta blocker Management • SGLT2i • Mineralocorticoid • Diuretics for fluid overload Spot diagnosis 54-year-old man presents with severe central crushing chest pain which radiates to his jaw and arm. He has a Acute Coronary Syndrome past medical history of type 2 diabetes and high cholesterol. He is also a heavy smoker and rarely exercises. A young women has presented with pleuritic left sided chest pain and is not able to take a full breath. She is Pulmonary Embolism currently on the OCP and has recently came back from travelling 23-year-old tall and thin male has presented with sudden onset right sided chest pain and SOB. It is very Pneumothorax (spontaneous) sharp pain and worse on movement. This was sudden and during a hockey match with no history of trauma 55-year-old man presenting with sudden onset tearing chest pain radiating to the back and scapula. He has a Aortic Dissection significant history of hypertension and smoking A 65-year-old women presents with chest pain that improves when sitting up. The pain is sharp and doesn’t Acute Pericarditis last long. She has recently had an upper respiratory tract infection and still has a fever. There are ECG changes present A 60-year-old women experiences chest pain when walking up stairs. The pain resolves once taking her GTN Stable Angina spray and rest.Break timeCardio Examination Look ALL around the patient for a few moments for general inspection Tips for all When talking throughout say ”there is no evidence of …” rather than “I am examination looking for signs of …” stations PPE’T FORGET Introduction and ALWAYS examine from patients' right side Time yourself and PRACTICE until perfect Introduction Wash hands and don PPE (you Introduce yourself, Explain the examination will be told before OSCE what confirm patient name and establish consent the PPE requirements are) and DOB ** ALSO adjust bed to 45 angle, adequately expose patient and ask for pain (specifically in arm) General Inspection Inspect from end of bed: ECG leads • Patient looks comfortable at rest Pillows Inspection Hands à Arms à Face à Chest What do the images show? Hand inspection Arachnodactyly Finger clubbing Splinter Janeway lesion haemorrhage **Also assess for colour, tar staining and needle track marks Osler nodesArms and Neck • Temperature • Capillary refill time • Radial pulse à heart rate, volume, character, rhythm, radio radial delay and collapsing pulse Offer blood pressure but generally don’t need to actually perform. • Auscultate carotid artery THEN palpate it • JVP and hepatojugular reflex (can ask if needs to be performed) What do the images show? Face and Mouth inspection Kayser-Fleischer rings Conjunctival pallor Corneal arcus Xanthelasma ** Also high arched palate and dental hygiene Angular stomatitisChest Inspection • Inspect the anterior chest wall • Scars suggestive of previous surgery • Pectus excavatum • Pectus carinatum • Visible pulsations A–Midline Sternotomy (Most cardiac surgery,esp.CABG) C–Posterolateral thoracotomy (Most non-cardiac thoracic procedures) D–Clamshell; bilateral subpectoral (Lung transplantation) E–Left subclavicular (Pacemaker insertion) Heart areas • Mitral area – apex of heart • Aortic area – right second intercostal space • Pulmonary area – second left intercostal space • Tricuspid area – lower left sternal border Palpate then auscultate Palpation Palpate the chest to assess the location of the apex beat and to identify heaves or thrills. Apex Heaves Thrills th Palpable murmur Palpate apex beat at 5 Parasternal heave is intercostal space a precordial impulse midclavicular line that can be palpated Place hand horizontally and Displacement can Place heel of hand on place over 4 heart valve areas occur due to left sternal edge ventricular hypertrophy Auscultation Auscultate the four heart valves – using bell and diaphragm. Time with the carotid pulse Accentuation manoeuvres Aortic stenosis Aortic regurgitation Mitral regurgitation Mitral stenosis Auscultate over Auscultate over aortic Auscultate over mitral Auscultate over carotid arteries area with diaphragm. Sit area with diaphragm. Roll mitral area using bell. using diaphragm the patient forward and patient to left hand side Roll patient onto left while patient holds listen during expiration and listen during hand side and listen breath expiration during expirationAortic Mitral Aortic stenosis Mitral stenosis • Ejection systolic murmur • Mid diastolic murmur • Slow rising pulse Aortic regurgitation Murmurs Mitral regurgitation • End diastolic murmur • Pan systolic murmur • Collapsing pulse • Quinkes sign, De Mussets sign and Corrigans pulsationFinish exam Inspect posterior chest wall Auscultate lung fields Assess for sacral oedema Assess for pitting oedema Thank the patient, dispose of PPE, summarise your findings to examiner and what you would do next to complete Heart Failure Infective Prosthetic Coarctation of Aortic Stenosis Endocarditis Valve Aorta Tachypnoea and Midline sternotomy Radio-femoral tachycardia Fever scar delay **S yncope Multiple bruise Cool peripheries Heart murmur marks on arm Weak radial pulse **A ngina Raised JVP Osler nodes Click sound on Severe **Dyspnoea auscultation hypertension Displaced apex Thoracotomy scar Ejection systolic bheart soundrd Janeway lesions from repair murmur valveaortic Bi-basal fine Signs of heart Slow rising carotid crepitations Tachycardia failure pulse (occasionally) Peripheral oedema Splinter Splinter **SAD acronym haemorrhage haemorrhageThank you! 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