• Requires some basic knowledge of clinical examinations

• Clinical examination station (OSCE)• One way to prepare: ‘Retrospective approach’• Cardiovascular examination: 2 cases• Respiratory examination: 2 cases

• Duration: 70 mins• Slides and recordings: www.bitemedicine.com/watch

• Other common OSCE cases available in previous and upcoming webinars• Aim of the week is to cover most of the common scenarios

2

Aims and Objectives

3

Clinical examination station: how to prepare?

EXAMINATION ROUTINE

PRESENTATION

VIVA

• Perform each step of the routine confidently

• Pick up on signs

• Present findings systematically

• List appropriate differentials based on findings

• Answer questions systematically

• Explain your thinking

‘Retrospective approach’1. Formulate an OSCE Cases List

2. Prepare your ‘VIVA’ for those cases• Positive signs of diagnosis• ‘Typical’ findings presentation• Risk factors• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

4

Clinical examination station: how to prepare?‘Retrospective approach’3. Finalise your examination routine

• Each step of the routine• Signs you are looking for• Your speech

4. Practice your examination routineon friends

5. Go to the wards/clinics looking foryour cases

EXAMINATION ROUTINE

PRESENTATION

VIVA

• Perform each step of the routine confidently

• Pick up on signs

• Present findings systematically

• List appropriate differentials based on findings

• Answer questions systematically

• Explain your thinking

What cases could come up?1. Mitral regurgitation2. Aortic stenosis3. Prosthetic heart valves: aortic, mitral or both4. Stable chronic heart failure5. Ischaemic heart disease: CABG scars

This is not a definitive list• But by preparing for these you will be better at:

• Your exam routine• Looking out for important signs• Formulating your findings systematically• Tackling the VIVA

5

Cardiovascular examination: OSCE Cases list

I performed a cardiovascular examination on this patient• Who has signs suggestive of mitral regurgitation

My main positive findings are:1. XXX2. YYY

My relevant negative findings are:1. XXX (Risk factors)2. YYY (Signs of decompensation)3. ZZZ (POSSIBLE associated features)

Overall, this points towards a diagnosis of mitral regurgitation withno signs of decompensation

6

How to present your findings?

If you have an idea, then back yourself from the start. It gets the examiner listening

RELEVANT negatives

99% of the time your patient will be STABLE

Peripheral

Pulse• Irregularly irregular

7

Cardiovascular examination: Case 1

Central

Auscultation• Pansystolic murmur

• Loudest at the mitral region• Exacerbated on patient lying on

their L side and on held expiration• Radiation to axilla

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Question 1

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Cardiovascular examination: Case 1 – Mitral regurgitationWhat is a pan-systolic murmur?• Lasts entire duration between S1 & S2

• Does not change in intensity

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Cardiovascular examination: Case 1 – Mitral regurgitationWhat is a pan-systolic murmur?• Lasts entire duration between S1 & S2

• Does not change in intensity

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Cardiovascular examination: Case 1 – Mitral regurgitationWhy is mitral regurgitation associated with an irregularly irregular pulse?• Mitral regurgitation = MV valve doesn't close

properly

(1)

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Cardiovascular examination: Case 1 – Mitral regurgitationWhy is mitral regurgitation associated with an irregularly irregular pulse?• Mitral regurgitation = MV valve doesn’t close

properly

• So when the LV starts to contract, blood is regurgitated from the LV back into the LA

(1)

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Cardiovascular examination: Case 1 – Mitral regurgitationWhy is mitral regurgitation associated with an irregularly irregular pulse?• Mitral regurgitation = MV valve doesn’t close

properly

• So when the LV starts to contract, some blood is regurgitated from the LV back into the LA

• Over time, LA becomes dilated

(1)

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Cardiovascular examination: Case 1 – Mitral regurgitationWhy is mitral regurgitation associated with an irregularly irregular pulse?• Mitral regurgitation = MV valve doesn’t close

properly

• So when the LV starts to contract, some blood is regurgitated from the LV back into the LA

• Over time, LA becomes dilated à LA starts to remodel à affects the electrical conduction

• This leads to atrial fibrillation (irregularly irregular pulse)

Summary: In chronic MR, the L atrium remodels à this affects electrical conduction through the heart

(1)

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Cardiovascular examination: Case 1 – Mitral regurgitationPlease present your findings?

I performed a cardiovascular examination on this patient who has signs suggestive of MITRAL REGURIGTATION

My main positive findings are:

• I palpated an irregularly, irregular pulse, suggestive of atrial fibrillation

• On auscultation, I could hear normal 1st & 2nd heart sounds with a systolic murmur between S1 & S2

• The systolic murmur was:

• Character: pansystolic

• Region: loudest over the mitral region

• Augmentation: end-expiration with the patient lying on their left side

• Radiation: axilla

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Cardiovascular examination: Case 1 – Mitral regurgitationPlease present your findings?

My relevant negative findings are:

• No signs of vascular risk factors e.g. tar staining, tendon xanthomata

• No peripheral stigmata of infective endocarditis

• No scars to suggest coronary artery bypass graft or valve replacement

• No signs of decompensation e.g. pulmonary or peripheral oedema

This points towards a diagnosis of grade 3 mitral regurgitation complicated by atrial fibrillation

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Cardiovascular examination: Case 1 – Mitral regurgitationWhat are your differentials?1. Mitral regurgitation

2. Aortic stenosis • Ejection systolic murmur with radiation to carotids

3. Tricuspid regurgitation• Pansystolic murmur

• Heard loudest over lower L sternal edge• Augmented on held INSPIRATION• No radiation • Rarer

Acute ChronicInfective endocarditis Ischaemic injury to L ventricle à dilated MV

annulus

Rupture of papillary muscle (e.g. post MI) Calcification of MV annulus

Rheumatic heart disease

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Cardiovascular examination: Case 1 – Mitral RegurgitationWhat are possible complications of mitral regurgitation

Complications from the valve• Infective endocarditis

Complications from impaired outflow• Left ventricular failure • Atrial fibrillation

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Cardiovascular examination: Case 1 – Mitral regurgitationHow would you investigate this patient?

Bedside• Basics observations: HR, BP, RR, SpO2• Urine dip: glycosuria for diabetes• ECG:

• AF• P-mitrale (broad, notched P waves): sign of dilated LA

Bloods• Inflammatory markers: CRP and ESR for infective

endocarditis• BNP: raised if associated heart failure

(2)

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Cardiovascular examination: Case 1 – Mitral regurgitationHow would you investigate this patient?

Imaging• CXR

• L atrial enlargement• Signs of heart failure (ABCDE)

• ECHO: gold standard test to diagnose & assess severity• Severe: Jet width > 0.7cm, regurgitant volume >

60mls

Special• Coronary angiography: measure gradient across valve

and assess for concomitant coronary artery disease(3)

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Cardiovascular examination: Case 1 – Mitral regurgitationHow would you manage this patient?

Conservative• Improve cardiovascular risk factors e.g. smoking cessation

Medical

• Anticoagulation for AF

• Manage heart failure if present

• ACEi, beta-blockers, diuretics

Surgical

• Valve repair or replacement indicated if:

• Symptomatic

• Severe LV dilation

• Significantly reduced LVEF

• New-onset AF

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Grading murmursFreeman & Levine Grading for heart murmurs

• Grade 1: Faintest murmur• Grade 2: Faint murmur• Grade 3: Loud murmur, no thrill• Grade 4: Loud murmur + palpable thrill• Grade 5: Murmur heard with stethoscope partially on chest + thrill• Grade 6: Murmur heard with stethoscope held off chest

Peripheral

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Cardiovascular examination: Case 2

Central

Auscultation• Bibasal crackles

(4) (5)

(6)

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Question 2

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Cardiovascular examination: Case 2 – Congestive cardiac failurePlease present your findings?

I performed a cardiovascular examination on this patient who has signs suggestive of CHRONIC HEART FAILURE

My main positive findings are:

• Tar staining • Finger prick marks suggesting blood glucose monitoring• Peripheral oedema up to knees• I also noticed a vertical 6cm scar on the neck along the distribution of the carotid artery

suggestive of a carotid endarterectomy scar• On auscultation of the lung bases: bibasal crackles

26

Cardiovascular examination: Case 2 – Congestive cardiac failurePlease present your findings?

My relevant negative findings are:• No scars to suggest coronary artery bypass graft or valve replacement• Normal heart sounds, with no added sounds or murmurs• No peripheral stigmata of infective endocarditis

This points towards congestive cardiac failure• The presence of both pulmonary and peripheral oedema suggests an element of

decompensation

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Cardiovascular examination: Case 2 – Congestive cardiac failureWhat are the possible causes of heart failure?

• Heart failure is defined as inadequate cardiac output for the body’s requirements

• Can be classified as L or R sided heart failure

Left sided Right sided Ischaemic heart disease Left sided heart failure

Valvular disease• Mitral• Aortic

Valvular disease• Tricuspid• Pulmonary

Cor pulmonale • COPD• Fibrosis • PE• Obstructive sleep apnoea

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Cardiovascular examination: Case 2 – Congestive cardiac failureHow would you investigate this patient?

Bedside• Basics observations: HR, BP, RR, SpO2• ECG: L ventricular strain (LBBB and large amplitude QRS) or R ventricular

strain (RBBB and right axis)

Bloods• FBC: anaemia (causes or exacerbates heart failure)• BNP or NT-pro BNP• U&Es: renal function can be deranged in heart failure (cardiorenal

syndrome)• Screen for risk factors: diabetes, lipids

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Cardiovascular examination: Case 2 – Congestive cardiac failureHow would you investigate this patient?

Imaging• CXR

• ABCDE signs of heart failure• ECHO: gold standard test to diagnose & assess severity

• Assess left ventricular ejection fraction

(3)

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Cardiovascular examination: Case 2 – Congestive cardiac failureHow would manage CCF? MDT approach: GP, heart failure team (cardiologist, specialist nurses), occupational therpaist

Conservative• Stop smoking and diabetes control • Healthy diet and consider fluid restriction • Regular exercise

Medical• 1st line: Beta blocker and ACEi

• Add furosemide if evidence of fluid overload, as is the case here • 2nd line: add in aldosterone antagonist • 3rd line: consider cardiac resynchronisation therapy or implantable cardiac defibrillator

Surgery• Heart transplant • Left ventricular assist device

• Given to patients unlikely to survive until heart donor becomes available

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Cardiovascular examination: Case 2 – Congestive cardiac failureNew York Classification of heart failure

Grading SymptomsGrade 1 No SOB

Grade 2 SOB with exertion• Slight limitation of physical activity

Grade 3 SOB with exertion• Marked limitation of physical activity • Mild activity causes symptoms

Grade 4 SOB at rest

What cases could come up?

1. Surgical: Lobectomy/Pneumonectomy

2. Pulmonary fibrosis

3. Bronchiectasis

4. COPD

5. Pleural effusion

6. Lung malignancy

32

Respiratory examination: OSCE Cases list

Peripheral

33

Respiratory examination: Case 1

Central

End of the bed:• Audible wet cough from the end of

the bed

Auscultation:• Coarse crackles which change on

coughing• Occasional wheeze

(7)

(8)

34

Question 3

35

Respiratory examination: Case 1 – Bronchiectasis

Please present your findings?

I performed a respiratory examination on this gentleman who has signs of BRONCHIECTASIS

My main positive findings are:• Audible productive cough • Long acting anti-muscarinic inhaler at the bedside• Digital clubbing• On auscultation:

• Coarse crepitation's that altered on coughing

36

Respiratory examination: Case 1 – BronchiectasisPlease present your findings?

My relevant negative findings are:• Reassuringly, not requiring oxygen currently• No CO2 retention flap • No signs of decompensation (e.g. cor pulmonale – raised JVP and peripheral oedema)

This points towards a diagnosis of bronchiectasis

• The patient displayed no evident signs of an underlying cause e.g. rheumatoid arthritis

• The commonest causes of bronchiectasis are idiopathic and post-infection, which I suspect may well be the case in this patient

37

Respiratory examination: Case 1 – Bronchiectasis

(9)

38

Question 4

39

Respiratory examination: Case 1 – Bronchiectasis What are the possible causes of bronchiectasis

Cause ExamplesCongenital Cystic fibrosis

Kartgener’s syndromePrimary ciliary dyskinesia Yellow nail syndrome

Post-infection MeaslesTBAspiration

Immunological dysfunction Rheumatoid arthritis Inflammatory bowel diseaseABPAHypogammaglobulinemia

40

Respiratory examination: Case 1 – BronchiectasisWhat are the differentials?

• Bronchiectasis: think of possible causes• Fibrosis

Bronchiectasis FibrosisProductive cough (Sputum pot) Dry cough

Coarse crackles which change on coughing

Fine end-inspiratory crackles

41

Respiratory examination: Case 1 – Bronchiectasis

Cardiology Respiratory Abdominal Infective endocarditisCyanotic heart diseaseAtrial myxoma

AbscessBronchiectasisCancerDefinitely not COPDEmpyemaFibrosis

Inflammatory bowel diseaseCoeliac diseaseChronic liver disease

What are the respiratory causes of clubbing?

42

Respiratory examination: Case 1 – BronchiectasisHow would you investigate this patient?

Bedside• Basic obs: HR, BP, RR, SpO2

• Sputum MCS: screen for infection or colonisation

• H.influenzae and P.aeruginosa

Bloods

• FBC and CRP: evidence of infection

• ABG: respiratory failure

43

Respiratory examination: Case 1 – BronchiectasisHow would you investigate this patient?

Imaging • CXR: tramlines and ring shadows

• CT thorax: signet ring sign

Special tests

• Spirometry: obstructive pattern with FEV1/FVC < 0.7

• Screen for underlying aetiology: RF, immunoglobulins, sweat test

Restrictive Obstructive

FEV1 or ↓ ↓

FVC ↓

FEV1/FVC >70% <70%

44

Respiratory examination: Case 1 – Bronchiectasis

(10)

45

Respiratory examination: Case 1 – Bronchiectasis

(11)

46

Respiratory examination: Case 1 – BronchiectasisHow would you treat this patient?MDT approach: respiratory team, GP, occupational therapists

Conservative• Pulmonary rehabilitation

• Immunisations

Medical

• Bronchodilators and/or inhaled corticosteroids

• Long-term antibiotics: azithromycin

• Mucolytics

Surgical

• Lobectomy

• Lung transplantation

Peripheral• Fine tremor

47

Respiratory examination: Case 2

Central

• Reduced cricosternal distance• Hyper-resonant percussion• Global polyphonic wheeze

(9) (4)

48

Question 5

49

Respiratory examination: Case 2 – COPDPlease present your findings?

I performed a respiratory examination on this patient who has signs of chronic obstructive pulmonary disease

My main positive findings are:

• A fine tremor suggesting beta agonist use

• Evidence of tar staining

• A reduced cricosternal distance with hyper-resonant percussion suggesting lung hyperexpansion

• On auscultation, a global polyphonic wheeze

• Pitting peripheral oedema suggesting cor pulmonale

50

Respiratory examination: Case 2 – COPDPlease present your findings?

My relevant negative findings are:

• No signs of mediastinal shift: central trachea, apex beat non-displaced

• No signs of decompensation (no CO2 retention flap)

• No signs of other treatment e.g. no supraclavicular scar (seen for surgery for TB)

This points towards chronic obstructive pulmonary disease• The patient has evidence of a smoking history which is the likely underlying

cause• He also has evidence of cor pulmonale

51

Respiratory examination: Case 2 – COPDWhat are the differentials?

• COPD: think of possible causes• Elderly: smoking• Young: alpha-1-antitrypsin deficiency

• Asthma

COPD Asthma Older patient + Evidence of smoking Younger patient +/- smoking

Beta-agonists Anti-muscarinicInhaled corticosteroids

Beta-agonistsAnti-muscarinics not usedInhaled corticosteroids

52

Respiratory examination: Case 2 – COPDHow would you investigate this patient?

Bedside• Basic obs• Sputum MCS: screen for infection or colonisation

• H.influenzae and S.pneumoninae

• ECG: evidence of right heart failure e.g. RBBB and right axis

Bloods• FBC and CRP: evidence of infection

• ABG: type 2 respiratory failure

• Alpha-1-antitrypsin

53

Respiratory examination: Case 2 – COPDHow would you investigate this patient?

Imaging • CXR: hyperexpansion +/- infection. CT not usually required

• Echocardiogram: evidence of heart failure

Special tests

• Spirometry: obstructive pattern with FEV1/FVC < 0.7

Restrictive Obstructive

FEV1 or ↓ ↓

FVC ↓

FEV1/FVC >70% <70%

(12)

54

Question 6

55

Respiratory examination: Case 2 – COPDHow would you treat this patient?MDT approach: respiratory team, GP, occupational therapists

Conservative• Smoking cessation and nicotine replacement

• Pulmonary rehabilitation

• Immunisations

Medical

• Bronchodilators and/or inhaled corticosteroids• Mucolytics

• LTOT

Surgical

• Lung volume reduction

• Lung transplantation

56

Respiratory examination: Case 2 – COPDIndications for LTOT?

LTOT is indicated in non-smokers with:• PaO2 <7.3 kPa OR

PaO2 ≥7.3 and <8 kPa AND 1 of the following:• Secondary polycythaemia• Peripheral oedema• Pulmonary hypertension

57

Top decile question

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Recap‘Retrospective approach’1. Formulate an OSCE Cases List2. Prepare your ‘VIVA’ for those cases

• Positive signs of diagnosis• ‘Typical’ findings presentation• Risk factors• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

3. Finalise your examination routine• Each step of the routine• Signs you are looking for• Your speech

EXAMINATION ROUTINE

PRESENTATION

VIVA

• Perform each step of the routine confidently

• Pick up on signs

• Present findings systematically

• List appropriate differentials based on findings

• Answer questions systematically

• Explain your thinking

61

References

1. Wikicommons. Modified by JHeuser from the modified version by Dake of the original heart diagram by Wapcaplet. uploaded: 15. April 2006 {{cc-by-sa-2.5,2.0,1.0}} {{WikimediaAllLicensing}}

2. Mrug / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)3. Frank Gaillard / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)4. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)5. U/ttriber. https://i.redd.it/ls1p27ofe4i41.jpg6. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)7. Desherinka / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)8. Wikicommons. RonEJ. Public domain. 9. National Heart Lung and Blood Institute / Public domain10. Mcgfowler / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)11. Hellerhoff / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)12. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

All other images were acquired under the basic license from Shutterstock and not suitable for redistribution

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Further information

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