Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score Location: You are a junior doctor based in an outpatient clinic. You have been asked by your consultant to perform a full cardiovascular examination. Patient: Pat Keyne, a 78 year old presenting to outpatient clinic Task: – Examine this patient’s cardiovascular system – Talk through your examination whilst examining, stating any key positives and negatives – After 6 minutes you will be asked a series of questions by the examiner You are a 78 year old patient, Pat Keane, who has attended outpatient clinic. You are happy to be examined by the junior doctor. After the candidate auscultates your heart, play this clip: https://oscestop.education/wp-content/uploads/2022/03/Pansystolic-murmur.mp3 There is no other abnormal pathology to simulate. Category Question Done Excellent Consent Candidate appropriately introduced themselves with: Full name Role Clarifies who they are examining Gains consent for examination Examination introduction Examination introduction Washes hands Appropriate exposes patient Positions patient correctly at 45 degrees Inspection Inspection from end of bed Observes patient from end of bed Comments on general appearance (well/unwell) Comments if they look comfortable, alert, breathless, pallored, cyanosed Comments if oxygen, fluids or monitoring is in place Peripheral examination Peripheral examination, comments examining for Capillary refill time Temperature normal Finger clubbing Splinter haemorrhages Tendon xanthomata Pulses Examines for pulses Radial pulse rate and rhythm Collapsing pulse – no marking point if candidate does not ask if any shoulder / doesn’t explain procedure Radio-radial delay Face Face examined for: Malar flush Corneal arcus Conjunctival pallor Central cyanosis Neck Neck examined for: Carotid pulse volume and character JVP Inspection Closer chest inspection for Presence of cardiac devices Scars Palpation Palpation for: Apex beat – 5th intercostal space, midclavicular line Heaves Thrills Auscultation Auscultation, examiner prompt: “please explain to me the anatomical landmarks you are using as you examine the patient” Auscultates whilst palpating carotid pulse Aortic region (2nd right intercostal space) Pulmonary region (2nd left intercostal space) Tricuspid region (Left lower sternal edge i.e 4/5th intercostal space) Apex region (Left 5th intercostal space mid-clavicular line) Auscultation extended Auscultation heart sounds extended Carotid auscultation Patient rolled onto left hand side, listening over apex, at expiration Patient sitting forwards, at third intercostal space left sternal edge Auscultation - pathology photo_camera After the candidate finishes auscultation of the heart, play this clip and ask them to comment Heart sounds one and two present Presence of pansystolic murmur Extra Auscultation extra-precordium Auscultation of lung bases Checks for sacral oedema Checks for pitting oedema over shin Finishing Finishing remarks Invites patient to dress again Re-washes hands Offers to view observation chart (including BP, HR, O2 sat and T) Question What is the diagnosis? Pansystolic murmur Mitral regurgitation (or tricuspid regurgitation) Question How would you differentiate between mitral regurgitation and tricuspid regurgitation? Tricuspid regurgitation is loudest at the lower left sternal edge; whereas, mitral regurgitation is loudest at the apex Mitral regurgitation radiates the the axilla Mitral regurgitation is louder on expiration (lEft-sided); tricuspid regurgitation is louder on inspiration (rIght-sided) Question What are the causes of mitral regurgitation? Papillary muscle dysfunction (post-MI) Structural degeneration Rheumatic heart disease Congenital: marfans and ehlers-danlos Dilated cardiomyopathy Submit your answers to get your score.