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Praecordium OSCE Revision Kelly McCartanWhat examinationof the praecordium consists of: To perform an examination of the praecordium includes: • Inspection • Palpation for the apex beat, thrills and heaves • Auscultation of the heart. The full Cardiovascular Exam is usually not necessary for Year 1 OSCE station however this would include the rest of the cardiovascular system including: general observation, hands, pulses, blood pressure, JVP and the face and mouth How do we begin everyOSCE station? WASH HANDS and INTRODUCTION CHECK NAME& DOB CLEAN STETHESCOPE Hello my name is … Can I check your and I am a first year name and DOB? medical student. EXPLANATION AND CONSENT I Have been asked to do cardiovascular exam on As I require adequate you, which will involve me having a look at yexposure of your chest, would chest and having a listen with my stethoscope. you mind removing your Is that ok? shirt for me? For the purposes of this examination, I’m just going to And can I just check if position the bed at 45 degrees. you are in any pain? Inspection Observe the patient : Patient is A – Alert, B – (normal) Body habitus, C – Comfortable at rest - Any shortness of breath, pallor, erythema etc. Any Scars? • Median sternotomy scar - Indicates presence of previous coronary artery bypass or cardiac valve surgery • Lateral thoracotomy scar - Indicates previous mitral valvotomy • Subclavian scar may be due to a Pacemaker • Assess for chest deformity: • Pectus excavatum (Marfan’s syndrome) • Pectus carinatum Palpate the chest to assess the location of the apex beat and to identify heaves or thrills Palpation Apex beat •Palpate the apex beat with your fingers placed horizontally across the chest. •In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant. •Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy. Heaves •A parasternal heave is a precordial impulse that can be palpated. •Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves. •If heaves are present you should feel the heel of your hand being lifted with each systole. •Parasternal heaves are typically associated with right ventricular hypertrophy. Thrills •A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur). •You should assess for a thrill across each of the heart valves in turn (see valve locations below). •To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed. Valve locations • in the midclavicular line.tal space • Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge. • Pulmonary valve: 2nd intercostal space at the left sternal edge. • Aortic valve: 2nd intercostal space at the right sternal edge.Auscultation DO NOT FORGET!! Palpate the carotid pulse to determine the first heart sound . Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the carotid pulse: 1. Mitral area 2. Tricuspid area 3. Pulmonary area 4. Aortic area Now with the Bell component of the stethoscope listen to the •Mitral area •Tricuspid areaAccentuationmanoeuvres 1. Roll the patient on to their left lateral position. Palpate for the apexbeat and listen with the bell component of your stethoscope for the murmur of mitral stenosis. Also listen into the axilla area for the murmur of mitral i.competence 2. Ask the patient sit forward: listens to aortic and tricuspid areas with the diaphragm at the end of expiration for aortic incompetence 3. Listens over both carotid arteries while the patient holds their breath for radiation of aortic stenosis or carotid bruits To completethe examination… ➢ Explain to the patient that the examination is now finished and tell them they can put their shirt back on. (!!) ➢ Thank the patient for their time. ➢ Dispose of PPE appropriately and wash your hands. ➢ Summarise your findings.Furtherassessments and investigations Other relevant examinations considered: • eg. peripheral oedema, auscultates lung bases, examination of peripheral pulses • Measure blood pressure: to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection. • Peripheral vascular examination: to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology. • Record a 12-lead ECG: to look for evidence of arrhythmias or myocardial ischaemia • . • Dipstick urine: to identify proteinuria or haematuria which can be associated with hypertension. • Bedside capillary blood glucose: to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease.Conclusion ❖Confidence is KEY ❖Remember to palpate carotid pulse while auscultating first and second heart sounds ❖Learn where to use diaphragm and bell of stethescope