1. Cardiology PULSE: Preparation for Finals Tutor name

2. TuBS attendance • https://tutorialbooking.com/

3. Session overview • Common cardiology conditions for the OSCE • How to present your findings • Overview of cardiac scars/murmurs/pulse characteristics • Case presentations and viva questions

4. What is the purpose of an OSCE? “This station tests a student’s ability to perform an appropriate focussed physical examination, demonstrating consideration for the patient, and to report back succinctly describing the relevant findings. It also tests a student’s clinical judgement i.e. the ability to decide the differential diagnosis, choose investigations and formulate a management plan.”

5. Common cardiology conditions in the OSCE • Murmurs – systolic, diastolic • Cardiac surgery • CABG • Valve replacement • Pacemaker • Infective Endocarditis • Heart failure

6. Presenting your findings • What were you asked to do? • What were your key positive findings? • What were the important negative findings? • What does this mean? • How would you complete your examination, and what investigations would you do?

7. Example • Mrs X presented with shortness of breath and chest pain. I performed a cardiovascular examination. • At the end of the bed she looked comfortable at rest and in no distress. • In terms of the positive findings, she had a slow rising pulse and also a heaving apex beat. • She also had an ejection systolic murmur heard loudest in the aortic area which radiated to the carotids. • There was no stigmata of endocarditis or heart failure. • The most likely differential diagnosis would be…

8. Completing your examination • Like to look at the observation chart – for… • Abdominal examination and palpate peripheral pulses • Urine dip (haematuria for endocarditis, glucose for diabetes) • Fundoscopy (for hypertensive or diabetic changes) • Respiratory examination • Anything you realise you have missed out!

9. Investigations

10. Cardiac scars Practise presenting!

11. Median Sternotomy • CABG • Transplant • Correction of congenital defects

12. Left anteolateral thoracotomy

13. Grafts

15. Cardiac murmurs

16. Systolic Murmurs For each sound clip 1 2 • Describe the murmur • What are the associated features? • What are the common causes? • What is the treatment?

17. Systolic Murmurs

18. Systolic Murmurs

19. Systolic Murmurs

20. Diastolic Murmurs For each sound clip 1 2 • Describe the murmur • What are the associated features? • What are the common causes? • What is the treatment?

21. Diastolic Murmurs

22. Pulse characteristics

23. Identify these pulse characteristics.

24. Clinical signs

25. What does this picture show? • Roth spots • Retinal haemorrhages with pale centre • IE

26. Case 1

27. Case 1 • 60year old gentleman, looks comfortable at rest • Hands – no clubbing, CRT<2s, tar staining • Eyes –xanthalesma, corneal arcus • Chest – midline sternotomy scar. • Precordium: HS I+II+0, no murmur • Legs – no peripheral oedema, long scar on the medial side of the left leg Please present your findings.

28. Case 2

29. Case 2 Comfortable at rest. HR 72bpm, regular Slow rising. No stigmata of endocarditis BP = 110/90 JVP + 2 cm above clavicle Apex beat not displaced.

30. Case 2 - thorax No heaves or thrills, HS I + II + a grade 3/6 ejection systolic murmur, loudest in the aortic area in expiration, radiating to the carotids. Clear lung fields, no pedal oedema Please present your findings.

31. Case 3

32. Case 3 - general Male, late middle age. Looks well, scattered purpura on arms, old midline sternotomy scar. Ticking patient.

33. Case 3 - examination Hands – No stigmata of endocarditis Pulse – 72 BPM, regular. Normal character JVP – not elevated Chest – no heaves or thrills. Apex – non displaced MCL Auscultation – Loud metallic second heart sound. Nil added Lung fields – Clear No pedal oedema

34. Case 4

35. Case 4 xanthelasma • Gentleman – late middle age • Pulse 80 bpm irreg • BP 160/80 • JVP - ?? Nicotine staining

36. Case 4 - chest Midline sternotomy

37. Case 4 – cardiac auscultation • No heaves or thrills • HS present, nil added

38. Case 4 - legs Grafts

39. Case 5

40. Case 5 - general

41. Case 5 – observations and chest • Pulse 92 • BP 130/80 • JVP elevated +6 cm above clavicle • Crackles at lung bases

42. Case 5 - auscultation • Apex laterally displaced in anterior axillary line, 5th ICS, with palpable thrill • Heart sounds soft S1, normal S2 • Pan-systolic murmur, 4/6, loudest in expiration radiating into axilla

43. Case 5 - legs

44. Case 6

45. Case 6 – general • Jaundiced, thin • HR 80 BPM, irregular • Prominent neck veins with large shoots of blood going up neck with each heartbeat • JVP - ?.. Examiner stops you when you go to do hepatojugular reflex…

46. Case 6 - auscultation • 3/6 pansystolic murmur heard loudest at left sternal edge in inspiration • Lung bases clear • Pitting oedema to mid shin Thinking ahead you examine the abdomen… What do you find? Please present your findings.

47. Case 7

48. Case 7 - general • Young man, comfortable at rest. • Capillary pulsations in the nailbeds. • Pulse 60bpm, regular and collapsing.

49. Case 7 - thorax • BP 130/60 • Visible carotid pulsations • JVP not elevated. • Thrusting apex beat displaced to the mid axillary line. • Early diastolic murmur (2/4) loudest in aortic area in expiration. • Lungs clear, no pedal oedema

50. More clinical signs! Please present the finding.