History Questions
- History of heart disease?
- Pain /tightness/ crushing/ gripping feeling in chest ? Is it associated with neck, left arm, or jaw pain? Sweating?
- Palpitations ?
- Blood pressure problems (high or low)?
- Fainting (Syncope) or dizziness when standing from sitting/lying
- Shortness of breath at rest? with activity or when lying down?
- Peripheral vascular disease symptoms? (swelling of the ankles, varicose veins, leg cramps on walking, numbness, coldness, weakness, colour/skin change in LL)
- Complicating or risk factors of vascular disease present? (diabetes, smoking, high cholesterol, breathing disorders, high BMI)
- Chronic systemic diseases or recent infections or illnesses.
- Smoker or history of smoking
- Recent surgery or dental work?
- Current medication
- Psychological or mental health problems?
Patient Preperation
- Explains procedure
- Obtains consent
Patient Position
- Patient supine with practitoiner on the right hand side
Observation
- General appearance, behavior, signs of distress
Posture, basic presenting appearance and behaviour. Patients with MI may present pale, sweaty, nauseous, short of breath, characteristically flexed and holding their chest and is in pain and is scared and anxious. Commonly feels faint and movement is difficult
Vitals
Temp, Pulse, Respiratory rate, BP
In healthy adults, the pulse should be between 60-100 bpm.
- A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome).
- A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism).
- An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.
Causes of a collapsing pulse
- Normal physiological states (e.g. fever, pregnancy)
- Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
- High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
Blood pressure abnormalities
- Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
- Hypotension: blood pressure of less than 90/60 mmHg.
- Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
- Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
- Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
Inspection Hands
Hands: Perfusion, clubbing, nail changes, tar stains
Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
Clubbing: Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
Inspection of Radial Pulse
Rate, Rythem, Volume
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
Inspection of Head and Neck
- Face: Colour (cyanosis/ pallor)
- Eyes: Palpebral conjunctiva pallor , Xanthelasmata
- Mouth: Central/Peripheral cyanosis, dental hygiene. Tongue changes.
- Neck: Carotid or venous prominence or pulsations.
Carotid Pulses
Palpate one at a time and then auscultate on held inspiration
Inspection of the Chest
Chest: Shape, masses, scars. Visible pulsations / apex beat.
- Scars suggestive of previous thoracic surgery: see the thoracic scars section below.
- Pectus excavatum: a caved-in or sunken appearance of the chest.
- Pectus carinatum: protrusion of the sternum and ribs.
- Visible pulsations: a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.
Palpation of Chest Wall
Apex beat
- Palpate the apex beat with your fingers placed horizontally across the chest.
- In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant.
- Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy.
Heaves
- A parasternal heave is a precordial impulse that can be palpated.
- Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
- If heaves are present you should feel the heel of your hand being lifted with each systole.
- Parasternal heaves are typically associated with right ventricular hypertrophy.
Thrills
- A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
- You should assess for a thrill across each of the heart valves in turn (see valve locations below).
- To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Auscultation of Heart Valves
