Osce Checklist Cardio Y2

Front 1

How to take the JVP

Back 1

1. patient supine at 30-45º head turned slightly to left

2. lanmark the IJV between 2 heads of SCM

3. measure ht of JVP above sternal angle (>3cm above SA = elevated)

4. adjust patient angle as needed

Front 2

Abdominojugular reflex: when to perform

Back 2

perform if unclear which pulsation is JVP, or if the JVP appears normal but you still suspect HF

Front 3

How to perform AJ maneuver

Back 3

apply 20-30mmHg pressure over abdomen

positive maneuver confirms elevated JVP (can be transient or sustained

Front 4

apex: 3 things to comment on

Back 4

1. position: MCL at 5th ICS

2. Size: quarter

3. movement: sustained/not sustained

Front 5

palpation for thrills and heaves

Back 5

1. palpate 4 cardinal areas for thrill (= grade IV or more)

2. palpate for RV heave

Front 6

Tamponade: General inspection expected findings

Back 6

potential dyspnea, \

reduced LOC if hypotensive

peripheral edema

Front 7

Expected vital signs in tamponade

Back 7

BP: low, pulsus paradoxus 20-50mmHg

HR: high

RR: high

Temp: NA

Sats: potentially reduced

Front 8

how to measure pulsus paradoxus

Back 8

1. note SBP where first Korotkoff sound heard

2. deflate cuff slowly and note pressure at which K sounds remain constant through inspiration and expiration

3. difference btw these two pressures = PP

Front 9

PP in pericarditis vs. tamponade

Back 9

pericarditis: PP <20 mmHg

tamponade: PP 20-50mmHg

Front 10

Systematic inspection in tamponade (relevent findings)

Back 10

Dyspnea

Neck: JVP (NO KUSSMAUL'S, ie should increase with expiration)

Front 11

JVP findings in tamponade 2

Back 11

1. absent y descent

2. No Kussmaul's sign (this would be present in constrictive pericarditis)

Front 12

tamponade: palpation findings 2

Back 12

1. hepatomegaly

2. edema (palpate lower limbs for pitting edema)

Front 13

auscultation: tamponade 2

Back 13

muffled heart sounds at all locations

pericardial rub possible

Front 14

Vitals in LHF

Back 14

BP: ±, or decreased

HR: inc

RR: inc.

Temp: NA

Sats: dec.

Front 15

CHF vitals: carotid pulse

Back 15

usually normal, reduced if AS is causing their CHF..

Front 16

JVP in LHF: ht

Back 16

elevated >3cm above SA

Front 17

JVP in LHF: Waveform

Back 17

prominent outward systolic wave (CV wave)

Front 18

JVPin LHF: Kussmaul

Back 18

positive Kussmaul can indicate severe LHF

Front 19

JVP: AJ test: when to perform?

Back 19

when JVP is normal but HF suspected

Front 20

LHF: precordial inspection

Back 20

SEADS

Front 21

LHF: precordial palpation 3

Back 21

Apex (size, location, sustained)

Thrills: palpate at 4 cardinal areas

Parasternal Heave

Front 22

LHF: auscultation

Back 22

1. S1 S2

2. S3 (vol. loaded)

3. Murmurs: AS, AR, MS

Front 23

3 murmurs that can cause LHF

+ Murmur that can result from LHF

Back 23

1. AS: systolic ejection murmur

2. AR: early diastolic decrescendo murmur

3. MS: diastolic rumble

and MR if LV dilates enough..

Front 24

Abdo exam in LHF

Back 24

pulsatile liver = Tricuspid regurg

Front 25

LHF Palpation: extremities

Back 25

pitting edema

Front 26

Auscultation of lungs in LHF

Back 26

crackles in pulmonary edema

absent breath sounds in pleural effusion

Front 27

next prompt: diff't AS from a benign functional murmur

Back 27

k

Front 28

Vitals in AS

Back 28

BP: low pulse pressure

HR: ±, low and slow pulse, comment later

RR: ±

Temp: ± (35.4-37.8)

Sats: ±, low if hypoperfusing

Front 29

Pulse in AS (2 important findings)

Back 29

palpate carotid: pulsus parvus et tardis

brachioradial delay or apical carotid delay

Front 30

JVP in AS

Back 30

normal, unless the LHF is present and has caused RHF

Front 31

precordial inspection in AS

Back 31

SEADS

visible impulses

respiratory effort

Front 32

Abdo inspection in AS

Back 32

ascites, edema

Front 33

extrem inspection in AS

Back 33

edema

Front 34

Palpation of precordium

Back 34

1. thrills and pulsations in 4 cardinal areas

2. apical impulse (sustained)

3. RV heave

4. apical-carotid delay or brachioradial delay

Front 35

Auscultation in AS

Back 35

1. 4 cardinal areas

2. S1, S2 (s2 diminished if calcified valve)

3. S3, S4.

4. murmurs!!

Front 36

Murmur of AS vs. Functional murmur

location, timing, radiation, Frequency

Back 36

1. Location: R base

Front 37

description of murmurs: SCRIPT

Back 37

A mnemonic to remember what characteristics to look for when listening to murmurs is SCRIPT: Site, Configuration (shape), Radiation, Intensity, Pitch and quality, and Timing in the cardiac cycle.

Front 38

Murmur of AS vs. functional murmur

1. site

2. configuration (shape)

3. Radiation

4. Intensity

5. Pitch

6. Timing

Back 38

1. site: AS at R base, functional m. over LSB or L base

2. shape: AS = crescendo decrescendo

3. radiation: AS radiates to carotids

4. intensity

5. pitch: AS = high pitch due to large pressure gradient

6. timing: AS = early, mid, late, holosystolic

Front 39

How does AS affect other heart sounds

Back 39

notable: softer S2 if calcified valve

others not so important

• S3, S4

• reversed S2 splitting

• narrow pulse pressure

Front 40

summary: 7 key findings of AS

Back 40

1. late peaking systolic murmur over aortic area with broad apical-base radiation

2. sustained impulse

3. delayed carotid artery upstroke

4. absent or diminished S2

5. prolonged murmur

6. apical carotid delay

7. reduced carotid a. volume

Front 41

MR: general appearance

Back 41

sick/not sick/distress

quick screen cyanosis

plethoric

diaphoretic

dyspnea

Front 42

MR: vitals

Back 42

BP: low in acute MR (query cardiogenic shock)

HR: normal, fast, possibly irregularly irregular

RR: fast or normal

T: elevated if infectious cause of MR

SAO2: normal or low

Front 43

MR: inspection: HEENT

Back 43

Central cyanosis

Conjunctival hemorrhage (IE)

ROth spots on retina (IE)

Front 44

MR inspection: Neck

Back 44

JVP !!

Front 45

MR inspection: Hands:

Back 45

• peripheral cyanosis

• evidence of IE (janeway lesions: hemorrhagic cutaneous lesions on palms and soles)

• splinter hemorrhage (nails) (IE)

• osler nodes: painful subQ nodes in distal finger (IE)

Front 46

MR Inspection abdomen

Back 46

ascites, pulsatile liver, heart failure stuff

Front 47

periphery (MR inspection)

Back 47

edema

Front 48

MR inspection: Chest

Back 48

SEADS, sternal shape

Front 49

MR palpation: chest

Back 49

thrills, (4 areas)

heave

apical impulse

Front 50

MR palpation: abdo

Back 50

pulsatile liver

Front 51

MR palpation: periphery

Back 51

pitting edema

Front 52

MR ascultation

Back 52

S1, S2 (may have loud S2)

S3 (chronic), S4 (acute); listen with bell

comment on regularity

Murmurs

Front 53

Murmur of MR (acute and chronic)

SCRIPT + maneuver to bring murmur out.

(1. site 2. configuration (shape) 3. Radiation 4. Intensity 5. Pitch 6. Timing)

Back 53

High-pitched pansystolic blowing murmur at the apex that radiates to axilla. diastolic flow rumble may be heard in chronic MR

Isometric handgrip increases murmur (due to increased afterload).

Front 54

next prompt: exam of suspected RHF from pulmonary edema

Back 54

k

Front 55

RHF: gen appearance

Back 55

Well/not well

dyspnea

pallor

diaphoresis, etc.

Front 56

RHF: ask for vitals /offer to assess

Back 56

k

Front 57

Pulses in RHF 5

Back 57

palpate

1. radial

2. femoral

3. popliteal

4. posterior tibial

5. dorsalis pedis

Front 58

RHF: do the JVP!!

Back 58

will either be elevated, or can perform Abdominojuglar test if JVP normal but RHF suspected..

Front 59

JVP finding in tricuspid regurg

Back 59

large V wave that blends with C wave

result = monophasic "CV wave"

Front 60

review: performing the AJ maneuver and commenting on findings

Back 60

20-30 mmHg of pressure on abdomen for 10s.

normal response: transient rise in JVP

abnormal response (and positive test) = sustained rise in JVP.

Front 61

RHF: inspection

Back 61

hands: cyanosis, nail beds, cap refil

HEENT: cyanosis

Neck: JVP if you haven't already

Chest: SEADS, hair loss

abdomen: pulsatile liver

legs: edema

Front 62

Palpation: RHF

Back 62

Chest: apical impulse, heaves, thrills

abdomen: pulsatile liver, ascites

legs: edema

Front 63

Auscultation RHF

Back 63

S1, S2,

S3, S4 (LLSB)

murmurs

Front 64

Murmur of TR: SCRIPT + maneuver to bring otu

Back 64

Pansystolic murmur heard over the LLSB in 4th interspace

accentuated by incr. venous return (inspiration, lift legs, etc)

Front 65

PVD: GA, vitals, etc same deal

Back 65

k

Front 66

PVD: inspection of legs 6

Back 66

expose legs

1. size, shape, symmetry, color

2. discoloration, swelling, rashes, scars, ulcers, abnormal venous patterns

3. ahir loss

4. nail beds

5. skin temp/difference btw legs

6. wounds and sores

Front 67

PVD: palpation of legs 5

Back 67

1. inguinal lymph nodes

2. PULSES: femoral popliteal, dorsalis pedis, posterior tibial pulses: PRESENT or ABSENT

3. pitting edema

4. coolness of foot

5. tenderness, muscle tension (DVT)

Front 68

PVD: auscultation of legs

Back 68

ausc. for bruits over femoral segment, iliac segment, over aorta.

bruits = stenosis

Front 69

PVD: special maneuvers: venous filling time

Back 69

raise legs 45 deg for 1 minute, then let patient sit up and dangle feet over edge of table.

abnormal test= >20sec for the vein to rise

Front 70

PVD: special maneuvers: cap refill time

Back 70

check toes, >5 sec is abnormal

Front 71

PVD: special maneuvers:Buerger test

Back 71

lift limb 90º till it becomes pale, slowly lower legs and note angle at which color returns to the feet.

Front 72

PVD: special maneuvers: ABI

Back 72

take BP of brachial a. on both sides. use highest value.

take bp at posterior tibialis and dorsalis pedis using BP cuff and doppler device. use highest systolic of the two.

ABI = P(leg)/P(arm) P >0.97