Makindo Medical Notes

Related Subjects: |Breast Anatomy and Examination (OSCE) |Shoulder examination(OSCE) |Testicular examination(OSCE) |Hernia Examination (OSCE) |Rectal examination (OSCE) |Liver Examination (OSCE) |Cerebellar Examination (OSCE) |Upper and Lower Limb Neurology (OSCE) |Gastroenterology Examination (OSCE) |Respiratory Examination (OSCE) |Cardiology Examination (OSCE)

Examination is an active process and one must be thinking and looking for things not expecting them to just jump out at you.

Introduction

• Wash your hands thoroughly before beginning the examination.
• Introduce yourself and confirm the patient’s name, date of birth, and reason for the visit.
• Explain the entire procedure and obtain informed consent.
• Ensure the patient is comfortably positioned (supine or semi-recumbent) with proper exposure of the chest while maintaining privacy.

Equipment Needed

• Examination gloves
• Stethoscope (with both diaphragm and bell)
• Sphygmomanometer (for blood pressure measurement)
• Pulse oximeter (optional, for oxygen saturation)
• Watch or timer (for pulse rate and timing maneuvers)
• Paper and pen (for documentation)

Step 1: General Inspection

• Observe the patient’s overall appearance, noting any signs of distress, cyanosis, or pallor.
• Inspect the chest wall for symmetry, deformities, scars, or evidence of previous surgery (e.g., sternotomy scars).
• Look for signs of CCF such as peripheral edema, raised jugular venous pressure (JVP), and digital clubbing.
• Assess the patient’s posture and breathing pattern, which can provide clues to cardiac function.

Step 2: Palpation

• Precordial Palpation:
  • Palpate the precordium to locate the point of maximal impulse (PMI), typically found in the 5th intercostal space at the mid-clavicular line.
  • Note the amplitude, size, and location of the PMI; a displaced or diffuse impulse may suggest ventricular enlargement.
  • Feel for any heaves (sustained lifts) or thrills (vibratory sensations) which indicate ventricular hypertrophy or turbulent flow.
• Chest Wall Assessment:
  • Palpate the entire chest wall gently for tenderness, masses, or abnormal pulsations.

Step 3: Auscultation

• Standard Auscultation Areas:
  • Aortic Area: Right 2nd intercostal space near the sternal border.
  • Pulmonic Area: Left 2nd intercostal space near the sternal border.
  • Tricuspid Area: Lower left sternal border (4th intercostal space).
  • Mitral Area (Apex): Left 5th intercostal space at the mid-clavicular line.
• Technique:
  • Use the diaphragm of the stethoscope to listen for high-pitched sounds (murmurs, S1, S2) and the bell for low-pitched sounds (S3, S4, diastolic murmurs).
  • Ask the patient to breathe normally; then, have them hold their breath if needed to better appreciate certain sounds.
• What to Listen For:
  • Normal heart sounds (S1 and S2): Should be clear and crisp.
  • Extra heart sounds:
    • S3: An early diastolic sound associated with volume overload or heart failure.
    • S4: A late diastolic sound indicating a stiff, hypertrophied ventricle.
  • Murmurs: Characterize by timing (systolic vs. diastolic), quality, intensity, and location. Use additional maneuvers to help differentiate their etiology.
  • Pericardial friction rub: A scratchy, creaking sound that varies with position and respiration, suggestive of pericarditis.

Step 4: Special Maneuvers

• Valsalva Maneuver: Ask the patient to bear down briefly. Murmur intensities may change (e.g., murmurs of hypertrophic cardiomyopathy usually increase during Valsalva).
• Handgrip Maneuver: Instruct the patient to perform a sustained handgrip (squeezing a ball or your hand). This increases afterload and can accentuate regurgitant murmurs such as mitral regurgitation.
• Left Lateral Decubitus Position: This position accentuates left-sided heart sounds (e.g., mitral stenosis and S3).

Step 5: Additional Assessments

• Blood Pressure and Pulse: Measure and record blood pressure and pulse rate/rhythm.
• Jugular Venous Pressure (JVP): With the patient at a 45° angle, inspect the neck for jugular venous distension; measure the vertical height of the JVP above the sternal angle.
• Peripheral Edema: Check for swelling in the lower extremities which may indicate heart failure.
• Carotid Bruits: Auscultate the carotid arteries (one at a time) to detect turbulent blood flow.

Step 6: Closure

• Thank the patient for their cooperation and ensure they are comfortable.
• Provide a brief summary of your findings and explain any further investigations or management plans if necessary.
• Help the patient to re-dress and ensure privacy before concluding the exam.
• Wash your hands again and document your examination findings accurately.

Table: Detailed Common Cardiac Examination Findings

Key Points for OSCE

• Follow a systematic approach: Inspection → Palpation → Auscultation → Special Maneuvers → Additional Assessments.
• Communicate each step clearly to the patient to reduce anxiety.
• Compare findings bilaterally and note any asymmetry.
• Be familiar with the characteristics of various heart sounds and murmurs, and use appropriate maneuvers to accentuate them.
• Accurately document your findings.

Common Pitfalls

• Inadequate exposure of the chest leading to missed findings.
• Rushing through the examination without a systematic approach.
• Failure to compare bilateral findings or assess additional maneuvers.
• Not explaining procedures properly, causing patient discomfort.

References & Further Reading

• Clinical Examination by Talley & O'Connor.
• Geeky Medics OSCE Resources
• OSCEstop – Online OSCE practice resources.