Gen Med Examination 2

Station 2

A sudden collapse

Start the Timer and Begin

Intro

Introduces self with name and job

Adheres to appropriate infection control measures

Gain consent for examination

Asks patient if they are any pain prior to beginning examination.

End of Bed Inspection

Adequately exposes the patient - all 4 limbs and face should be clearly visible, ideally removes shirt

Assesses patient from the end of the bed - patient looks well

Identifies findings around the examination space - examiner to please mention sports kit around the bed (or use props)

Peripheral Examination

Full marks

Visually inspects hands - no change

Cap refill - <2s

Radial pulse - rate, rhythm, character, and volume - as found in the actor

Checks for radial-radial delay and for collapsing pulse - as found in actor

Checks for 2 of;

Checks JVP - as found in the actor

Chest Exam: Look

Adequately exposes patient and visualised chest - chest appears normal, no scars

Chest Exam: Feel

Palpates Apex beat - displaced to 6th IC space, 3cm lateral to the midclavicular line

Palpates for parasternal heaves/thrills - nil

Chest Exam: Listen

Auscultates over the Pulmonary, Mitral, and Tricuspid valves - play the sound as the candidate auscultates

Auscultates over the Aortic valve - play the sound as candidate auscultates over the aortic valve

Verbilises a systolic murmur is heard over the aortic valve

Auscultates carotids for bruit - bruit present

Chest Exam: Special Manoeuvres

Performs accentuation manoeuvres - no accentuation during mitral manoeuvres

Performs accentuation manoeuvres - no accentuation present during aortic regurge manoeuvre

Performs accentuation manoeuvres - murmur accentuation during inhalation

Peripheral exam continued

Listens to the chest bases for pulmonary oedema - nil

Checks for sacral oedema and peripheral oedema in legs - nil

To Complete the Exam

Thanks patient and asks them to re-dress

Summarises the key findings using a structured approach

An Example of a good summary:

“Today I examined a 72 year old gentleman presenting with collapse. On examination the patient was cardiovascularly stable with no peripheral stigmata of cardiovascular disease. On closer examination I found an ejection systolic murmur consistent with aortic stenosis. This radiated to the carotids. There was no other audible valvular disease. To complete my exam I would do a peripheral vascular exam, perform an ECG, and discuss the case with a senior.”

Examiner Instruction

At this point please direct the candidate to interpret the ECG below

Interpretation & Diagnosis

Correctly identifies the name and date of the ECG

Candidate states the ECG shows a sinus rhythm

Candidate systematically checks the P wave, PR interval, QRS complec, ST segment, and T waves

Identifies tall QRS complexes and/or left axis deviation

Candidate identifies ECG is suggestive of ventricular hypertrophy

Main differential - Aortic Stenosis +/- left ventricular hypertrophy

Summary

THE MURMUR

A systolic murmur is typically either pulmonary/aortic stenosis or mitral/tricuspid regurgitation. Aortic stenosis is typically a crescendo decrescendo or “ejection systolic” murmur. Distinguishing murmurs based purely on sound is a skill. Often the location where the murmur is heard loudest is a better clue as to its origin. The volume of the murmur is not linked to severity of valvular disease as a severely failing aortic valve often doesn’t have the structural integrity to cause a flow murmur, instead it just flops out the way.

THE ECG

A left ventricle having to force blood through a narrowed aortic valve often becomes hypertrophied. This can cause a number of ECG changes including left axis deviation, large QRS complexes (both due to increased left sided muscle mass), and in extreme cases wide QRS complexes and T wave or ST changes (signifying left ventricular strain). The displaced apex beat supports cardiomegaly and hypertrophy.

THE REST OF THE STORY

On a deeper dive into Stephen’s history, it was noted that he had received radiotherapy several years ago. It was thought that this could have led to the valvular incompetence present on examination. A referral to cardiology was made for consideration of echo and potential valve replacement (TAVI).

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Station Written by: Dr Benjamin Armstrong

Peer Reviewed by: Dr Rishil Patel

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Gen Med Examination 2

Station 2

Candidate Instructions

Setting:

Name: Stephen Hedgeway

Tasks:

Simulated Patient Instructions

Briefing

Opening Statement

Appearance and Behaviour