LOCAS Cardiovascular Station How To Pass'''

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LOCAS Cardiovascular StationHow To Pass...

• Nick Peterson
• 5th Year

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Content

• Anatomy Physiology
• LOCAS Technique
• CVS Examination
• Murmurs
• Common Questions
• Any Questions

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Anatomy
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CORNEAL ARCUS
CLUBBING
MITRAL FACIES (MALAR FLUSH)
XANTHELASMA
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History

• Features of CVS disease to elicit
• Chest Pain
• Syncope
• Palpitations
• Exercise Tolerance (Fatigue)
• Dyspnoea (Posh for SOB)
• Ankle Swelling

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LOCAS EXAMINATION TECHNIQUE

• PRACTICE, PRACTICE, PRACTICE, PRACTICE
• PASS/FAIL FIRST MINUTE (within reason)
• STRUCTURE Have a system stick to it
• COMMENTARY
• BE HONEST
• PRACTICE
• NO SERIOUSLY, PRACTICE NOW

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LOCAS Examination Structure

• IMPORTANT OTHERWISE YOU END UP IN A MESS
• Introduction
• INSPECTION
• PALPATION
• (PERCUSSION)
• AUSCULTATION
• Summary

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Appearance

• First impressions count so ensure you look the
  part

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ExaminationFirst Minute

• VERY IMPORTANT
• Illegal ID Can Help People Purchase Ethanol
• Introduce, ID, Consent, Hands, Pain?, Position,
  Expose

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OBSERVATION INFORMATION
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Inspection

• From the END OF THE BED, LEFT SIDE.
• IN (Drips, Lines), ON (O2, Scars, Obvious),
  AROUND (Charts, Meds, ECG, Mobility)
• Patient
• General appearance
• General, Downs?, Marfans?, Turners?
• Colour
• Dyspnoea?
• Cachexia?
• COMMENT This patient looks ill/comfortable at
  rest.

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Hands

• Clubbing? LEARN YOUR CAUSES
• CVS
• Endocarditis
• Cyanotic Congenital Heart Disease
• Atrial Myxoma
• Splinter Haemorrhages?
• Peripheral Cyanosis?
• Tendon Xanthomata
• Palmar Creases
• Tar Staining (Reliable??)

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Pulse

• Radial Pulse
• Rate, Rhythm
• Radio-Radial delay
• Check for Collapsing Pulse (AR)
• ASK ABOUT SHOULDER OR WRIST PAIN FIRST
• Say to examiner At this stage I would usually
  check for radio-femoral delay and measure the
  blood pressure

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Face

• General Appearance?
• Conditions
• Specifics
• Anaemia
• Xanthelasma
• Corneal Arcus
• Cyanosis (CP)

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Head And Neck

• Carotid Pulse (rate/rhythm/volume/character/thrill
  -?auscultate first)
• JVP
• Height
• Raised Pulsatile RHF
• Raised Non-Puls SVCO
• Waveform
• Usually double complex waveform
• Hepato-Jugular Reflex
• BE HONEST

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Patient Lying Back - CHEST (Praecordium)

• Inspect
• Shape
• Scars
• Median Sternotomy
• CABG
• Valve Replacement
• Lateral Thoracotomy
• Mitral Valvotomy
• Pacemaker
• Apex
• Visible??
• Anything else

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Patient Lying Back - CHEST (Praecordium)

• Palpate
• Apex Beat
• Tapping (Palpable valve closure)
• Heaving (Sustained contraction)
• Thrusting (Hyperdynamic contraction)
• Thrills
• Parasternal heave

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Patient Lying Back - CHEST (Praecordium)

• Auscultate PALPATE CAROTID PULSE
• Apex with Bell
• Roll to L side
• At Apex During Held Expiration (MS)
• Roll back
• At Apex With Diaphragm (AND AXILLA FOR RADIATION)
• Tricuspid ? Pulmonary ? Aortic
• Carotids for radiation (If no A murmur Bruit)

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Patient Sits ForwardCHEST (Praecordium)

• PALPATE CAROTID PULSE
• Listen at Left Sternal Edge during HELD
  EXPIRATION for AR
• LEFT OUT

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Patient Sitting ForwardBACK

• INSPECT BACK
• Lung Bases
• Sacrum
• Lie Back
• Ankles

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Conclusion

• Ensure Patient is Comfortable and Covered
• Thankyou for letting me examine you today.
• Turn to examiner
• To finish my examination I would like to examine
  the peripheral pulses and abdomen, perform
  fundoscopy, dipstick the urine and review any
  recent investigations. In summary, this 75 year
  old gentleman

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YouTube Examination

• http//www.youtube.com/watch?vdp5m2tXHDmA

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What Comes Up

• Murmurs (In a minute)
• Often paediatric patients
• Congenital Heart Defects
• VSD, PDA etc.
• Associations of conditions (eg. Downs with AVSD)
• Prosthetic valves

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Murmurs
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Heart Sounds

• I II 0
• I 1st Heart Sound
• II 2nd Heart Sound
• 0 No Added Sounds

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Heart Sounds

• 1st heart sound Lub ???
• Closure of Mitral Tricuspid Valves
• 2nd heart sound Dub ???
• Closure of Aortic Pulmonary Valves
• 3rd heart sound (S3) Lub Dub De ???
• Early Diastolic - Rapid filling of ventricles
• 4th heart sound (S4) Le Lub Dub ???
• Late Diastolic - Atrial contraction filling a
  stiff left ventricle

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Murmurs

• Shape
• Length
• Quality of S1 S2
• Quality of murmur (Volume Characteristics)
• Location of murmur
• Radiation of murmur
• SCORED 1-6 (Above 3 Palpable Thrill)

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Mitral Regurgitation

• Plateau-like, Pan-Systolic, Quiet S1, Blowing,
  High-Pitched, Heard at Apex, Radiates to Axilla,

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Aortic Stenosis

• Crescendo-Decrescendo, Ejection systolic, Loud,
  Rough, Medium Pitched, Heard over Aortic Area,
  Radiates to Carotids

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Mitral Stenosis

• Plateau-like, Diastolic, Rumbling, Low-Pitched,
  Heard over Apex

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Aortic Regurgitation

• Tapering, Early-Diastolic, Low-pitched, Heard
  over Apex.

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S3

• Early Diastolic. Normal in children young
  adults
• Causes MR, VSD, CCF, Restrictive Pericarditis

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S4

• Late Diastolic Sound Always Abnormal
• Causes LVH, Amyloid, HCM, LV ischaemia

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Clicks

• Early Systolic
• Aortic Ejection
• Aortic Stenosis (with or without bicuspid valve)
• Pulmonary Ejection
• Pulmonary Stenosis
• Mid-Systolic
• Mitral Valve Prolapse

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Opening Snap

• Mitral Stenosis
• Early Diastolic, sound of mitral valve opening
• Closeness to S2 Severity
• Becomes absent in late disease when mitral cusps
  are immobile (calcification)

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AF

• Irregularly, Irregular Pulse
• Differential Multiple Ventricular Ectopics
• Causes SHIMMERS
• S Soaring BP (HTN)
• H Heart Failure
• I Ischaemic Heart Disease
• M MI
• M Mitral Valve Disease
• E Ethanol/Endocrine (Thyroid)
• R Respiratory (pneumonia, PE, bronchial Ca)
• S Sepsis/Sick Sinus Syndrome

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COMMON QUESTIONS ASKED BY THE EXAMINER
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Questions

• Differential Diagnosis
• Investigations
• Management
• Causes of murmurs
• Anatomy of Heart
• Anatomy of Aorta
• Explanation of symptoms
• Random

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RELAX
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GOOD LUCK!!!!