A dose of med school- 1st year cardio vascular exam

All medical students have to do at least 1 OSCE exam a year (at least in Canada, I think).  OSCEs,  which stands for ‘objective structured clinical examination’, are exams where students rotate through clinical stations, each approximately 10 minutes in length.  At each station an actor patient ‘presents’ with a certain medical concern and the student performs the relevant exam while an evaluator observes and scores the student.  At each station students are evaluated based on history/physical exam techniques, communication skills, organization, professionalism, etc.  For example, the station excerpt could be something like the following:

“Bob, a 60 year old male, presents with chest pain and shortness of breath.

Perform a focused cardiovascular exam.

 

As a medical student at this station you would usually have 2 minutes to prepare, then 10 minutes to perform the cardiovascular exam before moving on to the next OSCE station (which could be, history taking, respiratory exam, etc.).  Although I have never experienced a real OSCE yet, we have had 1 mock OSCE and I am currently preparing for my first real OSCE this April.

How do you prepare for an OSCE? OSCE prep is done throughout the year, with OSCE exams being cumulative (every clinical technique you have ever learned in medical school is fair game!).   At my medical school we have clinical once a week where we have pre-readings and videos for a particular clinical skill (for example, a cardiovascular exam), then have a volunteer patient for the afternoon, which we practice this skill on.  Curious about what a cardiovascular exam for the OSCE looks like for 1st and 2nd year med students?    Check out my study notes below, if you are unfamiliar with terms or are ambiguous on the concept try googling it 🙂  Google is a wonderful and essential tool for understanding lectures in medical school, doctorate in medicine should really be doctorate in wikipedia (not even joking).

 

So here we go the CARDIOVASCULAR EXAM

  • Introduction
    • Introduce yourself & title to the patient (ex, “My name is X and I am a first year medical student”)
    • How patient likes to be referred to as
    • Wash hands (don’t want to spread germs!)
    • Purpose of exercise (ex, “I will be performing a cardiovascular exam to further investigate your chest pain and shortness of breath, is that okay?”)
    • Confidentiality (you are not allowed to tell others the patients information unless you have the patients approval, the patient is underage or they are a risk to themselves or others)
    • Questions (make sure the ‘patient’ understands what is going on)
    • Ensure patient is comfortable and properly drape patient (only expose, the minimal, i.e. what you need to examine at that time)
  • ABCs –> ensure stability of patient
    • Airway
      • Paradoxical chest movement
        • Rib fracture
      • Accessory muscle use
        • Respiratory distress
      • Tracheal deviation
        • Unequal intrathoracic chest pressure- pneumothorax, pleural effusion, collapsed lung, cancers
      • Noisy air
        • Respiratory infection, asthma, tumor, edema, COPD, emphysema
      • Cyanosis
        • Poor circulation or inadequate oxygenation of blood)
      • Breathing
        • Respiratory distress
          • Accessory muscle use, position of patient, sweating, cyanosis
        • Respiratory rate –> rate, depth rhythm
          • Normal= 12-20/min
        • Chest deformity and movement
        • External breathing sounds
        • Auscultation and percussion of chest
      • Circulation
        • Color and temperature of extremities
        • Capillary refill
          • <2 seconds normal
          • Prolonged= shock, dehydration, decreased peripheral perfusion, peripheral vascular disease
        • Pulse –> regularity, strength, equality
          • 60-100 normal
        • Blood pressure
        • Heart auscultation

 

  • General inspection
    • Level of consciousness
    • Level of distress
    • Well vs. unwell appearance
      • Position
      • Facial expression
      • Breathing

 

  • Vitals
    • Blood pressure
    • Heart rate
    • Respiratory rate

 

  • Hands/wrists/fingers
    • Clubbing
      • Lung disease (lung cancer, COPD, TB, fibrosis)
      • Heart disease (chronic hypoxia, endocarditis)
      • Gastrointestinal (malabsorption, crohn’s disease, ulcerative colitis, cirrhosis)
    • Cyanosis (bluish tinge)
    • Capillary refill –> < 2 seconds (press against finger nail)
    • Radial (wrist just under thumb) and brachial (anterior aspect of elbow, medial to the tendon of the biceps) pulses
      • Amplitude= size/strength of pulse
      • Upstroke= how quickly pulse reaches maximum
      • Rate= frequency of pulse
      • Rhythm= regularity of pulse

 

  • Legs
    • Pedal edema (test by pressing against shin, edema is a type of ‘fluid build-up’ in the body)
      • Causes= venous insufficiency, heart failure, pulmonary hypertension, drugs, DVT, etc.
    • Pulses
      • Dorsalis pedis –> felt on top of foot between 1st and 2nd metatarsal bones
      • Posterior tibialis –> posterior to ankle bone, on inner aspect of ankle
    • Temperature (should be warm if limb receiving appropriate circulation)
    • Signs of chronic poor circulation
      • Loss of hair
      • Discoloration
      • Ulcer

 

  • Neck
    • Accessory muscle use
    • Carotid auscultation
      • Medial to SCM
    • Carotid palpation –> amplitude, upstroke, rate, rhythm
    • JVP inspection
      • Is the indirectly observed pressure over the venous system and haemodynamic changes in the right side of the heart
      • Normally should not be more then 4cm above sternal angle
      • Identifying JVP
        • Biphasic vs. monophasic
        • Changes with position vs. doesn’t
        • Increases with AJR vs. doesn’t
        • Changes with respiration vs. doesn’t
        • Non-palpable vs. palpable
        • Oblieratable vs. not
    • Back
      • Percuss the lungs (percuss is a special type of tapping, google it!)
      • Auscultate the lungs (auscultate means to listen using your stethoscope)
        • Crackles= pneumonia, pulmonary fibrosis, bronchitis, pulmonary edema (congestive heart failure)
        • Wheezes= asthma/COPD
      • Sacral edema
        • Lying down for long time

 

  • Chest
    • Inspect
      • Cardiac pulsations (visible lifts)
      • Scars and pacemakers (below clavicle)
      • Pectus excavatum
        • Caved in chest
        • Congenital, can impair cardiac and respiratory function
      • Pectus carinatum
        • Protrusion of chest

 

  • Palpate
    • Apex
      • Most lateral position
        • Apex beat usually 5th intercostal space, medial to mid-clavicular line
      • Size (how many interspace)
        • Normally size of quarter
      • Right ventricular heave
        • Lock elbow and place heel of hand to left of sternum
      • Percuss/auscultate the lungs
      • Auscultate the heart
        • Over aortic, pulmonic, tricuspid and mitral valves –> listen for S1, S2, S3, S4 and murmurs

APPENDIX

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ewr

 

 

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