cmecde 569

 

Oedema (non-pitting)

Venous ulcers

Varicose veins

Scars due to varicose vein surgery

Trendelenburg test

Perthes’ test (if after the gold medal)

[Note] The 6 Ps of limb ischaemia: pain, pallor, pulselessness, paraesthesia, paralysis, and perishingly cold.

Clinical Skills for OSCEs

36 Station 15

Ankle-brachial pressure index (ABPI)

Specifications: You are most likely to be requested to measure the ABPI for one arm and ankle only.

Calculating and interpreting ABPI

Figure 8. Calculating ABPI.

Table 7. ABPI interpretation

ABPI Interpretation

> 0.95

0.5–0.9

< 0.5

< 0.2

Normal

Claudication pain

Rest pain

Ulceration and gangrene

Higher of the two right ankle pressures

Higher of the two arm pressures

Higher of the two left ankle pressures

Higher of the two arm pressures

Right arm

systolic pressure

Left arm

systolic pressure

Right ankle

systolic

pressure

Left ankle

systolic

pressure

Posterior tibial

Dorsalis pedis

Posterior tibial

Dorsalis pedis

Right ABPI Left ABPI

Cardiovascular and respiratory medicine

Station 15 Ankle-brachial pressure index (ABPI) 37

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Position him at 45° with his sleeves and trousers rolled up.

• Ensure that he is comfortable.

• Wash your hands.

• State that you would allow him 5 minutes resting time before taking measurements.

The procedure

Brachial systolic pressure

• Place an appropriately sized cuff around the arm, as for any blood pressure recording.

• Locate the brachial pulse by palpation and apply contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff and record the pressure at which the signal reappears.

• Repeat the procedure for the other arm or state that you would do so.

• Retain the higher of the two readings.

Take care not to allow the probe to slide away from the line of the artery.

Ankle systolic pressure

• Place an appropriately sized cuff around the ankle immediately above the malleoli.

• Locate the dorsalis pedis pulse by palpation or with the hand-held Doppler probe and apply

contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff, and record the pressure at which the signal reappears.

• Repeat the procedure for the posterior tibial pulse, which is posterior and inferior to the medial

malleolus.

• Repeat the procedure for the dorsalis pedis and posterior tibial pulses of the other ankle orstate

that you would do so.

• For each ankle, retain the higher of the two readings.

After the procedure

• Clean the patient’s skin of contact gel and allow him time to restore his clothing.

• Clean the hand-held Doppler probe of contact gel.

• Wash your hands.

• Calculate the ABPI and explain its significance to the patient.

• Ask the patient if he has any questions or concerns.

• Thank the patient.

Clinical Skills for OSCEs

38 Station 16

Breathlessness history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the nature of his breathlessness, and obtain his consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint

• Ask about the nature of the breathlessness. Use open questions.

• Elicit the patient’s ideas, concerns and expectations (ICE).

History of presenting complaint

Ask about:

• Onset, duration, and variability of breathlessness.

• Provoking and relieving factors. Provoking factors include stress, exercise, cold weather, pets,

dust, and pollen; relieving factors include rest and use of inhaler or GTN spray.

• Severity:

– exercise tolerance: “How far can you walk before you get breathless? How far could you walk

before?”

– sleep disturbance: “Do you get more breathless when you lie down? How many pillows do you

use?”

– paroxysmal nocturnal dyspnoea: “Do you wake up in the middle of the night feeling breathless?”

• Associated symptoms(wheeze, cough,sputum, haemoptysis, fever, nightsweats, anorexia, loss

of weight, lethargy, chest pain, dizziness, pedal oedema).

• Effect on everyday life.

• Previous episodes of breathlessness.

• Smoking and alcohol.

Past medical history

• Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever),

PE/DVT, pneumonia, bronchitis, and tuberculosis.

• Previous investigations (e.g. bronchoscopy, chest X-ray).

• Previous hospital admissions and previous surgery.

Drug history

• Prescribed medication (especially bronchodilators, NSAIDs, b-blockers, ACE inhibitors,

amiodarone, and steroids) and route (e.g. inhaler, home nebuliser).

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Cardiovascular and respiratory medicine

Station 16 Breathlessness history 39

Family history

• Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic

fibrosis, tuberculosis, and emphysema (a1-antitrypsin deficiency).

Social history

• Smoking: 1 pack year is equivalent to 20 cigarettes per day for 1 year.

• Recent long-haul travel.

• Exposure to tuberculosis.

• Contact with asbestos (mesothelioma).

• Contact with work-place allergens involved in, for example, baking, soldering, spray painting.

• Contact with animals, especially cats, dogs, and birds (bird fancier’s lung).

After taking the history

• Ask the patient if there is anything else he might add that you have forgotten to ask.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to examine the patient and carry out some investigations to confirm

your diagnosis.

Conditions most likely to come up in a breathlessness history station

Asthma:

• Breathlessness, chest tightness, wheezing and coughing.

• Symptoms worse at night and in the early morning, and exacerbated by irritants, cold air,

exercise, and emotion.

• Symptoms respond to bronchodilators.

• There may be a history and family history of atopy.

Chronic obstructive pulmonary disease:

• Breathlessness, cough, wheeze.

• Chronic progressive disorder characterised by fixed or only partially reversible airway

obstruction (cf. asthma).

• History of smoking.

Pneumonia:

• Breathlessness accompanied by fever, cough, and yellow sputum, and in some cases by

haemoptysis and pleuritic chest pain.

Clinical Skills for OSCEs

40 Station 16 Breathlessness history

Tuberculosis:

• Breathlessness, cough, haemoptysis, weight loss, malaise, fever, night sweats, pleural pain,

symptoms of extrapulmonary disease.

• More likely in certain high-risk groups such as immigrants, the homeless and the

immunocompromised.

Pulmonary embolism:

• Breathlessness, sometimes with pleural pain and haemoptysis.

• There may be predisposing factors such as recent surgery, immobility, or long-haul travel.

Lung cancer:

• Symptoms may include breathlessness, stridor, cough, haemoptysis, anorexia, weight loss,

lethargy, pleural pain, hoarseness, Horner’s syndrome, effects of distant metastases.

• History of smoking in most cases.

Heart failure:

• Left ventricular failure leads to pulmonary oedema.

• Symptoms include breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, pedal

oedema.

• There is a cough which produces pink frothy sputum.

Panic attack:

• Rapid onset of severe anxiety lasting for about 20–30 minutes.

• Associated with chest tightness and hyperventilation.

41Cardiovascular and respiratory medicine

Station 17

Respiratory system examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45°, and ask him to remove his top(s).

• Ask him if he is in any pain or distress.

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health, nutritional status, and any other obvious signs). In particular, is he visibly breathless or cyanosed?

Does he have to sit up to breathe? Is his breathing audible? Are there any added sounds(cough,

wheeze, stridor)?

• Note:

– the rate, depth, and regularity of his breathing

– any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine

– any asymmetry of chest expansion

– the use of accessory muscles of respiration and planting of hands

– the presence of operative scars, including in the axillae and around the back

• Next observe the surroundings. Is the patient on oxygen? If so, note the device (see Tables 40

and 41 in Station 113), the concentration (%), and the flow rate. Look in particular for inhalers,

nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there

is a sputum pot, make sure to inspect its contents.

Inspection and examination of the hands

• Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated

by a bluish discoloration of the fingertips.

• Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less

than 2 seconds for the nail bed to return to its normal colour.

• Look fortarstaining and finger clubbing. When the dorsum of a fingerfrom one hand is opposed

to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s

window) is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is

obliterated, and a distal angle is created between the fingers (see Figure 9). Respiratory causes

of clubbing include carcinoma, fibrosing alveolitis, and chronic suppurative lung disease (see

Table 8).

• Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an

apical lung tumour that is invading or compressing the roots of the brachial plexus.

• Test for asterixis (see Table 9), the coarse flapping tremor of carbon dioxide retention, by asking

the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards.

Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine

tremor may be related to excessive use of B2 agonist.

• During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the

bounding pulse of carbon dioxide retention?

• Indicate that you would like to measure the blood pressure.

Clinical Skills for OSCEs

42 Station 17 Respiratory system examination

Table 8. The principal causes of clubbing

Respiratory causes

Bronchial carcinoma

Fibrosing alveolitis

Chronic suppurative lung disease

Cardiac causes

Infective endocarditis

Cyanotic heart disease

Gastrointestinal causes

Cirrhosis

Ulcerative colitis

Crohn’s disease

Coeliac disease

Familial

Table 9. The principal causes of asterixis

Hepatic failure

Renal failure

Cardiac failure

Respiratory failure

Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia)

Drug intoxication, e.g. alcohol, phenytoin

CNS causes

Inspection and examination of the head and neck

• Inspect the patient’s eyes. Look for a ptosis (an upper lid that encroaches upon the pupil) and

for anisocoria (pupillary asymmetry). Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis

are strongly suggestive of Horner’s syndrome, which may result from compression of the sympathetic chain by an apical lung tumour.

• Next inspect the sclera and conjunctivae for signs of anaemia.

• Ask the patient to open his mouth and inspect the underside of the tongue for the blue discoloration of central cyanosis.

• Assess the jugular venous pressure (JVP) and the jugular venous pulse form (see Station 13). A

raised JVP is suggestive of right-sided heart failure.

Figure 9. Clubbing. When the dorsum of a finger from one hand is opposed to the dorsum of a finger from the

other hand, a diamond-shaped window is formed at the base of the nailbeds. In clubbing, this diamond-shaped

window is obliterated, and a distal angle is created between the fingers.

cmecde 632

 

33Cardiovascular and respiratory medicine

Station 14

Peripheral vascular system examination

In this station you may be asked to restrict your examination to the arterial or venous system only. You

must therefore be able to separate out the signs for either (see Table 6).

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• After checking for any pain, ask him to expose his feet and legs and to lie down on the couch.

The examination

Inspection

• General appearance: body habitus, missing limbs or digits, surrounding paraphernalia such as

walking aids, oxygen, cigarettes.

• Skin changes: pallor, shininess, loss of body hair, atrophie blanche (ivory-white areas), haemosiderin ­pigmentation, inflammation, eczema, lipodermatosclerosis.

• Thickened dystrophic nails.

• Scars.

• Signs of gangrene: blackened skin, nail infection, amputated toes.

• Venous and arterial ulcers. Remember to look in the interdigital spaces.

• Oedema.

• Varicose veins (ask the patient to stand up). Varicose veins are often associated with incompetent valves in the long and short saphenous veins.

Do not make the common mistake of asking the patient to stand up before having

examined for varicose veins.

Palpation and special tests

• Ask about any pain in the legs and feet.

• Assess skin temperature by running the back of your hand along the leg and the sole of the

foot. Compare both legs.

• Capillary refill. Compress a nail bed for 5 seconds and let go. It should take less than 2 seconds

for the nail bed to return to its normal colour.

• Peripheral pulses (compare both sides).

– femoral pulse at the inguinal ligament

– popliteal pulse in the popliteal space (flex the knee)

– posterior tibial pulse behind the medial malleolus

– dorsalis pedis pulse over the dorsum of the foot, just lateral to the extensor tendon of the

great toe

• Buerger’s test:

– lift both of the patient’s legs to a 15 degree angle and note any collapse of the veins (‘venous

guttering’), which is indicative of arterial insufficiency

– lift both of the patient’s legs up to the point where they turn white (this is Buerger’s angle);

if there is no arterial insufficiency, the legs will not turn white, not even at a 90 degree angle

Clinical Skills for OSCEs

34 Station 14 Peripheral vascular system examination

– ask the patient to dangle his legs over the edge of the couch; in chronic limb ischaemia,

rather than returning to its normal colour, the skin will slowly turn red like a cooked lobster

(reactive hyperaemia)

• Oedema. Firm ‘non-pitting’ oedema is a sign of chronic venous insufficiency (compare to the

‘pitting’ oedema of cardiac failure).

• Varicose veins. Tenderness on palpation suggests thrombophlebitis.

• Trendelenburg’s test:

– elevate the leg to 90 degrees to drain the veins of blood

– occlude the sapheno-femoral junction (SFJ) with two fingers

– keep your fingers in place and ask the patient to stand up

– remove your fingers: if the superficial veins refill, this indicates incompetence at the SFJ

• Tourniquet test:

– elevate the leg to 90 degrees to drain the veins of blood

– apply a tourniquet to the upper thigh

– ask the patient to stand up: if the superficial veins below the tourniquet refill, this indicates

incompetent perforators below the tourniquet

– release the tourniquet: sudden additional filling of the veins is a sign of sapheno-femoral

incompetence

[Note] The tourniquet test can be repeated further and further down the leg, until the superficial veins below the

tourniquet no longer refill.

Auscultation

• Femoral arteries.

• Abdominal aorta.

• Renal arteries.

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• If appropriate, indicate that you might also measure the ABPI (see Station 15) and examine the

cardiovascular system and abdomen (aortic aneurysm).

Cardiovascular and respiratory medicine

Station 14 Peripheral vascular system examination 35

Table 6. Examination of the arterial or venous system only

Arterial system Venous system

Pallor

Shininess

Dystrophic nails

Loss of body hair

Arterial ulcers

Signs of gangrene

Skin temperature

Capillary refill

Peripheral pulses

Buerger’s test

Auscultation of femoral arteries and aorta

ABPI (if time permits, see Station 15)

Atrophie blanche

Pigmentation

Inflammation

Eczema

Lipodermatosclerosis

cmecde 5456

 

Cardiovascular and respiratory medicine

Station 12 Blood pressure measurement 27

Examiner’s questions

Causes of secondary hypertension:

• Endocrine causes:

– high catecholamines, e.g.

phaeochromocytoma

– high glucocorticoids, e.g. Cushing’s

syndrome

– high mineralocorticoids, e.g. Conn’s

syndrome

– high growth hormone, e.g. acromegaly

– hyper- or hypo-thyroidism

– hyperparathyroidism

• Renal disease

• Vascular causes:

– renal artery stenosis

– coarctation of the aorta

• Pregnancy:

– gestational hypertension

– pre-eclampsia (+ oedema and proteinuria)

• Drugs:

– NSAIDs, steroids, oestrogen, illicit drugs

Complications of hypertension:

• Cerebrovascular accident (haemorrhage or

ischaemic infarct).

• Retinopathy.

• Ischaemic heart disease.

• Left ventricular failure.

• Renal failure.

• Atherosclerosis.

• Aneurysm.

Investigations in hypertension:

• Confirming hypertension.

• Assessing for a possible secondary cause.

• Assessing for complications/end-organ

damage (see above) e.g. fundoscopy, ECG,

blood tests such as urea and electrolytes.

Artery

Stethoscope

Sphygmomanometer

Right arm

Cu

Figure 5. Positioning of the cuff and head

of the stethoscope.

Clinical Skills for OSCEs

28 Station 13

Cardiovascular examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45 degrees, and ask him to remove his top(s).

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health,

nutritional status, and any other obvious signs). Is he breathless or cyanosed? Is he coughing?

Does he have the malar flush of mitral stenosis?

• Observe the patient’s surroundings, looking in particular for items such as a nitrate spray, an

oxygen mask, ECG electrodes, and IV lines and infusions.

• Inspect the chest for any scars and the precordium for any abnormal pulsation. A median

sternotomy scar could indicate coronary artery bypass grafting (CABG), valve repair or replacement, or the repair of a congenital defect. A left submammary scar most likely indicates repair

or replacement of the mitral valve. Do not miss a pacemaker if it is there!

Inspection and examination of the hands

• Take both hands noting:

– temperature: feel with the back of your hand

– colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains

– nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds

– any presence of clubbing (endocarditis, cyanotic congenital heart disease)

– any presence of Osler nodes and Janeway lesions (subacute infective endocarditis)

– any presence of splinter haemorrhages (subacute infective endocarditis)

– any presence of koilonychia or ‘spoon nails’ (iron deficiency)

• Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular

rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests

atrial fibrillation or multiple ectopics.

• Raise the patient’s arm above his head to assess for a collapsing/water hammer pulse (aortic

regurgitation). Ask the patient whether he has any shoulder pain first.

• Simultaneously take the pulse in both armsto exclude radio-radial delay (aortic arch aneurysm).

Indicate that you would also exclude radio-femoral delay (coarctation of the aorta).

• As you move up the arm, look for bruising, which may indicate that the patient is on an anticoagulant, and for evidence of intravenous drug use, which is a risk factor for acute infective

endocarditis.

• Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure

is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 29

Inspection and examination of the head and neck

• Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate

hyperlipidaemia.

• Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivusfor pallor, which

is indicative of anaemia.

• Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor

dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan’ssyndrome).

• Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive

of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries

simultaneously.

• Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form:

ask the patient to turn his head slightly to one side, and look at the internal vein medial to the

clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees,

the vertical height of the jugular distension from the angle of Louis (sternal angle) should be

no greater than 4 cm: if it is greater than 4cm, this suggests right heart failure, fluid overload,

or tricuspid valve disease.

Palpation of the heart

Ask the patient if he has any chest pain.

• Determine the location and character of the apex beat. It is normally located in the fifth intercostal space at the midclavicular line. The apex may be:

– impalpable: obesity, dextrocardia, situs inversus…

– displaced, suggesting volume overload (mitral or aortic regurgitation)

– heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)

– ‘tapping’, suggesting mitral stenosis

• Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.

Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted

murmurs.

45°

Height of jugular

venous distention

Angle of Louis

(sternal angle)

4 cm

Figure 6. Assessing

the jugular venous

pressure.

Clinical Skills for OSCEs

30 Station 13 Cardiovascular examination

Auscultation of the heart

• Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stethoscope’s diaphragm, listen in the:

– aortic area

right second intercostal space near the sternum

– pulmonary area

left second intercostal space near the sternum

– tricuspid area

left third, fourth, and fifth intercostal spaces near the sternum

– mitral area (use the stethoscope’s bell)

left fifth intercostal space in the mid-clavicular line

• Manoeuvres and points to remember:

– ask the patient to bend forward and to hold his breath at end-expiration. Using the stethoscope’s diaphragm, listen at the left sternal edge in the fourth intercostal space for the middiastolic murmur of aortic regurgitation

– ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the

stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis

– listen over the carotid arteries for any bruits and the radiation of the murmur of aortic

stenosis

– listen in the left axilla for the radiation of the murmur of mitral regurgitation

For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ or

throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by

palpating the carotid or brachial artery to determine the start of systole. Grade the murmur on a scale

of I to VI according to itsintensity (see Table 4). Common conditions associated with murmurs are listed

in Table 5.

A P

T

M

Mid-clavicular

line

Auscultation points

C C

Ax

Figure 7. Auscultation points.

Cardiovascular and respiratory medicine

Station 13 Cardiovascular examination 31

Table 4. Grading murmurs

I Barely audible murmur

II Soft and localised murmur

III Murmur of moderate intensity that is immediately audible

IV Murmur of loud intensity with a palpable thrill

V As above, murmur audible with only stethoscope rim on chest wall

VI As above, murmur audible even as stethoscope is lifted from chest wall

Table 5. Common conditions associated with murmurs

Aortic stenosis Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best

heard in the aortic area and radiating to the carotids and cardiac apex

Mitral regurgitation Displaced thrusting cardiac apex, pan-systolic murmur best heard in the

mitral area and radiating to the axilla, patient may be in atrial fibrillation

Aortic regurgitation Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the

lower left sternal edge

Mitral valve prolapse Mid-systolic click, late-systolic murmur best heard in the mitral area

RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard

loudest on Expiration

Chest examination

• Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause

pulmonary oedema and pleural effusions.

Abdominal examination

• Palpate the abdomen to exclude ascites and/or hepatomegaly.

• Check for the presence of an aortic aneurysm.

• Ballot the kidneys and listen for any renal artery bruits.

Examination of the ankles and legs

• Inspect the legs for scars that might be indicative of vein harvesting for a CABG.

• Palpate for the ‘pitting’ oedema of cardiac failure: check for pain and then press for 5 seconds

on the patient’s legs. If oedema is present, assess how far it extends. In some cases, it may

extend all the way up to the sacrum or even the torso (‘anasarca’).

• Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in

both feet.

Clinical Skills for OSCEs

32 Station 13 Cardiovascular examination

After the examination

• Indicate that you would look at the observation chart, dipstick the urine, examine the retina

with an ophthalmoscope (for hypertensive changes and the Roth’s spots of subacute infective

endocarditis), and, if appropriate, order some key investigations, e.g. FBC, ECG, CXR, echocardiogram.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a cardiovascular examination station

• Murmurs (see Table 5).

• Heart failure.

• Median sternotomy scar, with or without scar on the lower leg (vein harvesting).

• Pacemaker.

cmecde 241

 Clinical Skills for OSCEs

22 Station 10 Chest pain history

Family history

• Parents, siblings, and children. Ask specifically about heart disease, hypertension, and other

heritable cardiovascular risk factors.

Social history

• Employment.

• Housing.

• Hobbies.

After taking the history

• Ask the patient if there is anything else that he might add that you have forgotten to ask. This is

an excellent question to ask in clinical practice, and an even better one to ask in exams.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to examine the patient and possibly order some investigations, in

particular:

• ECG to look for or help rule out ischaemic heart disease.

• Blood tests including

– troponins to look for or help rule out myocardial infarction

– D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the

diagnosis but a positive result does not confirm it)

– inflammatory markers such as white cell count and CRP for suggestion of pneumonia

• Chest X-ray for signs of pneumonia or pneumothorax.

• CTPA or V/Q scan if the history is suggestive of a pulmonary embolism.

Conditions most likely to come up in a chest pain history station

Angina:

• Heavy retrosternal pain which may radiate into the neck or left arm

• Brought on by effort or emotion and relieved by rest and nitrates

• Risk factors for ischaemic heart disease are likely

• A family history of ischaemic heart disease is likely

Myocardial infarction (MI):

• Pain typically comes on over a few minutes

• Pain is similar to that of angina but is typically severe, long-lasting (> 20 minutes), and

unresponsive to nitrates

• Often associated with sweating, nausea, and breathlessness

• Risk factors for ischaemic heart disease are likely

• A family history of ischaemic heart disease is likely

Cardiovascular and respiratory medicine

Station 10 Chest pain history 23

Pleuritic pain:

• Sharp, stabbing, ‘catching’ pain

• May radiate to the back or shoulder

• Typically aggravated by deep breathing and coughing

• Can be caused by pleurisy which can occur with pneumonia, pulmonary embolus, and

pneumothorax, or by pericarditis which can occur post-MI, in viral infections, and in autoimmune

diseases

• Pleural pain is localised to one side of the chest and is not position dependent

• Pericardial pain is central and positional, aggravated by lying down and alleviated by sitting up or

leaning forward

• Dressler’s syndrome (post-MI syndrome) is characterised by pleuritic chest pain from pericarditis

accompanied by a low-grade fever, and can occur up to three months following an MI

Pulmonary embolus:

• Sharp, stabbing pain that is of sudden onset

• May be associated with shortness of breath, haemoptysis, and/or pleurisy

• Typically aggravated by deep breathing and coughing

• May be a history of recent surgery, prolonged bed rest, or long-haul travel

Gastro-oesophageal reflux disease:

• Retrosternal burning

• Clear relationship with food and alcohol, but no relationship with effort

• May be associated with odynophagia and nocturnal asthma

• Aggravated by lying down and alleviated by sitting up and by antacids such as Gaviscon or milk

Musculoskeletal complaint e.g. costochondritis:

• May be associated with a history of physical injury or unusual exertion

• Pain is aggravated by movement, but is not reliably alleviated by rest

• The site of the pain is tender to touch

Panic attack:

• Rapid onset of severe anxiety lasting for about 20–30 minutes

• Associated with chest tightness and hyperventilation

Aortic dissection:

• Sudden onset, sharp, tearing pain that is maximal at the time of onset

• Radiates to the back

If you cannot differentiate angina from gastro-oesophageal reflux disease and there are

no signs of ischaemia on the ECG, advise an exercise ECG stress test. If this is negative,

consider a therapeutic trial of an antacid or a nitrate.

Clinical Skills for OSCEs

24 Station 11

Cardiovascular risk assessment

Cardiovascular risk factors can usefully be divided into fixed (non-modifiable) and modifiable risk

factors. Fixed risk factorsinclude older age, male gender, family history, and a South Asian background.

Modifiable risk factors include hypertension, hyperlipidaemia, diabetes, smoking, alcohol, exercise,

and stress. Having one or more of these risk factors does not mean that a person is going to develop

cardiovascular disease, but merely that he is at increased probability of developing it. Conversely,

having no risk factors is not a guarantee that a person is not going to develop cardiovascular disease.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questionsto assess hisrisk of cardiovascular disease

(coronary heart disease, cerebrovascular disease, vascular disease) and obtain consent.

Remember to be tactful in your questioning, and to respond sensitively to the patient’s

ideas, concerns and expectations (ICE).

The risk assessment

If this information has not already been provided or disclosed, find out the patient’s reason for

attending. Then note or enquire about:

Fixed risk factors

1. Age and sex.

2. Ethnic background. People from a South Asian background are at a notably higher risk of

cardiovascular disease.

3. Past cardiovascular events, e.g. MI or stroke. If the patient has a history of past cardiovascular

events, you are assessing him for secondary rather than primary prevention.

4. Family history. Ask about a family history of cardiovascular disease and risk factors for

cardiovascular disease such as hypertension, hyperlipidaemia and diabetes mellitus.

Modifiable risk factors

5. Hypertension. If hypertensive, ask about latest blood pressure measurement, time since first

diagnosis, and any medication being taken.

6. Hyperlipidaemia. If hyperlipidaemic, ask about latest serum cholesterol level, time since first

diagnosis, and any medication being taken.

7. Diabetes mellitus. If diabetic, ask about medication being taken, level of diabetes control

being achieved, time since first diagnosis, and presence of complications.

8. Cigarette smoking. If a smoker or ex-smoker, ask about number of years spent smoking and

average number of cigarettes smoked per day. Does the patient also smoke roll-ups and cannabis? Does he use illicit drugs such as cocaine?

9. Alcohol. Ask about the number of units of alcohol consumed in a day and typical week. Note

that depending on the amount and type that is drunk, alcohol can be either protective or a

risk factor.

10. Diet. In particular, ask about fried food and takeaways.

11. Lack of exercise. Ask about amount of exercise taken in a day or week. Does the patient walk

to work or walk to the shops?

12. Stress. Ask about occupational history and home life.

Cardiovascular and respiratory medicine

Station 11 Cardiovascular risk assessment 25

Table 2. Desirable lipid levels

Total cholesterol < 5.0 mmol/l

LDL ‘bad’ cholesterol (fasting)  3.0 mmol/l

HDL ‘good’ cholesterol  1.2 mmol/l

Total cholesterol/HDL cholesterol < 4.5

Tryglycerides (fasting) < 1.5 mmol/l

NB. Patients at high risk of cardiovascular disease should aim

for even better than these figures.

After the assessment

• If you have time, assess the extent of any cardiovascular disease.

• Ask the patient if there is anything he would like to add that you may have forgotten to ask

about.

• Give him feedback on his cardiovascular risk (e.g. low, medium, high), and, if appropriate,

indicate a further course of action (e.g. further investigations or further appointment to discuss

reducing modifiable risk factors).

• Address any remaining concerns.

• State to the examiner that appropriate investigations include:

– BMI (should be between 18.5kg/m2 and 24.9kg/m2

)

– waist circumference (should be less than 102cm for men and 89cm for women)

– blood pressure (should be under 140/90mmHg)

– fasting blood glucose levels (should be under 6.0mmol/L)

– fasting lipid levels (see Table 2)

• Suggest calculating the patient’s 10-year cardiovascular risk score using the Framingham risk

equation, which takes into account a number of risk factors including gender, age, total cholesterol, HDL cholesterol, smoking status, and blood pressure.

• Indicate that the management of cardiovascular risk factors includes lifestyle modification and,

if appropriate, medical intervention (see Table 3).

Table 3. Management of cardiovascular disease

Lifestyle modification Medical intervention

Advise patient to:

• Stop smoking.

• Reduce alcohol intake (to 3–4 units/day

in men and 2–3 in women, and avoid

binges).

• Lose weight.

• Adopt a healthy diet: reduce saturated

fatty acids, trans-fatty acids and

cholesterol; increase fibre and omega-3

fatty acids, e.g. from fish.

• Take 30–60 minutes of exercise per day.

• Consider statin for secondary prevention

or for primary prevention if 10-year risk is

>20%.

• Consider anti-platelet drugs e.g. aspirin.

• Consider anti-hypertensive agents.

• If necessary, seek to optimise blood sugar

control.

Clinical Skills for OSCEs

26 Station 12

Blood pressure measurement

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Tell him that he might feel some discomfort as the cuff is inflated, and that the blood pressure

measurement may have to be repeated.

Avoid white coat hypertension by putting the patient at ease. Briefly discuss a nonthreatening subject, such as the patient’s journey to the clinic, or the weather.

The procedure

• Select an appropriately sized cuff and attach it to the BP machine. This is usually a standard cuff

in all but children and the obese.

• Position the BP machine so that it is roughly at the level of the patient’s heart.

• Position the measurement column/dial so that it is at eye level (avoids parallax error).

• Position the patient’s right arm so that it is horizontal at the level of the mid-sternum and free

from obstructive clothing.

• Locate the brachial artery at about 2 cm above the antecubital fossa.

• Apply the cuff to the arm, ensuring that the arterial point/arrow is over the brachial artery.

• Inflate the cuff to 20–30 mmHg higher than the estimated systolic blood pressure. You can estimate the systolic blood pressure by palpating the brachial or radial artery pulse and inflating

the cuff until you can no longer feel it.

• Place the stethoscope over the brachial artery pulse, ensuring that it does not touch the cuff.

• Reduce the pressure in the cuff at a rate of 2–3 mmHg per second.

– the first consistent Korotkov sounds indicate the systolic blood pressure

– the muffling and disappearance of the Korotkov sounds indicate the diastolic blood pressure

• Record the blood pressure as the systolic reading over the diastolic reading. Do not attempt

to ‘round off’ your readings; to an examiner’s ear, 144/88 usually rings more true than 140/90.

• If the blood pressure is higher than 140/90, indicate that you need to take a second reading

after giving the patient a one minute rest.

• In some situations, it may be appropriate to record the blood pressure in both arms (to investigate coarctation or dissection of the aorta), and also with the patient lying and standing (to

investigate for postural hypotension: a drop in BP on standing of ≥20mmHg).

After the procedure

• Ensure that the patient is comfortable.

• Tell the patient his blood pressure and explain its significance. Hypertension can only be confirmed by several blood pressure measurements taken over an extended period of time.

• Thank the patient.

• Document the blood pressure recording in the patient’s notes.