BATESVISUALGUIDETOPHYSICALEXAMINATION

OSCE1:ChestPain

Thisvideoformatisdesignedtohelpyouprepareforobjectivestructuredclinicalexaminations,or
OSCEs.
Youaregoingtoobserveandparticipateinaclinicalencounterofapatientwhocomestotheoffice
withacomplaintofchestpain.
Asyouobservetheencounter,youwillbeaskedtoanswerquestionswhiletheimageonthescreen
freezes.Suchquestionswillallowyoutopracticehistorytakingandphysicalexaminationskillsaswellas
yourclinicalreasoningskillsindevelopinganassessmentordifferentialdiagnosisandaplanthatis,an
appropriatenextdiagnosticworkup.
Youwillhavetimetorecordyourfindingsandreceivefeedback.

HealthHistory
Tellmeyourspecialconcernstoday.
ImalittleworriedbecauseIhavebeenhavingsharppainsinmychestforthelasttwoweeks.
Whatfindingsmightbeimportanttolookforasyouobservethispatient?
Levelofdistress.
Laboredbreathing.
Skincolor:centralandperipheralcyanosis.
Respiratoryrate.
TwoweeksagoIwasreadingastoryinthepaperaboutacarcrash,whenInoticedsharppainsinmy
leftchest.Iwassweatingandshortofbreathforabout5minutes.Andmyheartfeltlikeitwasracing.
Whatpossiblecausesofchestpainareyouconsidering?
Angina.
GERD.
Panicattack.
Musculoskeletalchestwallpain.
Canyoutellmehowseverethepainwas,onascalefrom1to10,with1beingveryfaintand10being
severe?

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Iwas5over10.

Diditmoveintoyourneckordownyourleftarm?
No,noitwasjustinmychest.
Howhaveyoubeensincethen?
Ivehadtwootherepisodes,oneofthemwasabout10daysagowhenIwasliftingsomebooks,the
otherwasabout5daysagowhenIwastalkingwithmysisteraboutourfathersdeath.Hedied3
monthsagoinacarcrash.
Didyouhaveanyothersymptomswhenyouhadthesechestpains?
Yes,Ihadthesamesweatingandshortnessofbreath,withsomelightheadednessduringthemost
recentone.
Whatwasthelevelofpain?
Thesame,about5outof10forabout5minutes.ThenthepainjustwentawaywhileIwassittingthere.
Ikeepfeelingsolostandpanickedsincemyfatherdied.
Howareyoufeelingtoday?
TodayImfeelingfine,butIhaventbeensleepingwell.Itsstrange,Ineverfeltanxiousordepressed
before.
Whatcardiovascularriskfactorsdoyouneedtoconsiderinthispatient?Andwhichonehasthehighest
riskforcoronaryarterydisease?
Theriskfactorsare:
Familyhistoryofcoronaryarterydisease.
Hyperlipidemia,hypertension,smoking,diabetes.
Forwomen,preeclampsiaandcollagenvasculardisease.
Familyhistoryconveyshighestrisk.
Doyouhaveanyproblemswithacidreflux?Orhaveyoudoneanyheavyliftingorstrenuousexercise?
No,IveneverhadanystomachproblemsandIdontreallyexercisemuch.
Doyouhaveahistoryofhighbloodpressure?Inoticedtodayyourbloodpressurewas140over95.
Yes,wellIdidhavehighbloodpressureduringmythreepregnancies,Ithinkitwasabout145over90,
butthedeliverieswerefine.
Whataboutsmoking?

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WhenIwasinmy20sIsmokedaboutapackadayforabout4years.
Doyoudrinkanyalcohol?
Ihave1or2glassesofwinemaybe3nightsaweek,morerecentlytohelpmerelax.
Isthereanyheartdiseaseinyourfamily?
Yes,mybrotherhadbypasssurgerywhenhewas48,andmymomdiedofaheartattackwhenshewas
62.
Whatabouthighcholesterol,oristhereanydiabetesinthefamily?
No,Iveneverhadtroublewithmycholesterolandwedonthavediabetesinmyfamily.
Youvegivenmeagoodpictureofyoursymptoms,andIcanseewhyyoureconcerned.Isthere
anythingyouthinkwemayhavemissed?
No,butIcantgetawayfromtheseflashbacksaboutmyfathersaccident.
Itscommontovisualizesceneslikeacrashwithalovedone.Letsdoyourphysicalexamination,and
thenwecantalkmore.

PhysicalExamination
Iseeyourbloodpressureis150over95andyourheartrateis95today.Thesearebothsomewhat
elevated.Iwouldliketobeginbyexaminingyourlipsandnailsforcolorandthenlistentoyourlungs.
Okay.
Examinelipsandnailsforcyanosis.
Okay,looksgood.
Percussthenauscultateposteriorlungsinladderpattern.
Takeadeepbreath.
Listentothelungsmakingsuretolistentotherightmiddlelobeunderaxilla.
Onemoretime.
[BREATHINGINANDOUT]
Illbeexaminingthevesselsinyourneck,andthenyourheart.Sopleaseliebackwithyourfeetstraight
out.
Examinetheneckfirst.
Assessthejugularvenouspressure.

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Findthehighestpointofoscillationintheinternaljugularvein
andmeasuretheverticaldistancefromthesternalangle.
Palpatecarotidupstroke.
Thenormalupstrokeisbrisk,smooth,andrapid,andfollowsS1almostimmediately.
Largeboundingupstrokesindicateaorticinsufficiency.
Listenforabruit,whichisawhooshing,murmurlikesoundoftenfromatheroscleroticnarrowingofthe
carotidartery.Abruitsoundslikethis:
[BRUIT,WHOOSHINGMURMUR]
Okay,Imgoingtocheckthetappingimpulsepointofyourheart.
Palpatethepointofmaximalimpulse.Youcandothisandlistentotheheartsoundsbylisteningunder
thegownwithoutexposingthechest.
Youmaynoticetappingwhichistimedatthebeginningofsystole.Thepointofmaximalimpulsemay
besustainedordiffuse,meaningspreadovermorethanoneintercostalspace.
ListenforS1andS2ineachofthesixlisteningareas:intheaorticareaintherightsecondinterspace
closetothesternum;inthepulmonicareaintheleftsecondinterspaceclosetothesternum;intheleft
thirdinterspace;inthetricuspidareaintheleftfourthandleftfifthinterspaces;andinthemitralareaat
theapex.
Usethediaphragmattherightuppersternalborderandthelowerleftsternalborder.
Usethebellattheapex.
Listentoandpalpatetheabdomen.
Thefollowingfindingsmaybeheardinthecardiacauscultationofthispatient.Canyouidentifythese
heartsounds?
[HEARTBEAT]
S4isalowpitcheddiastolicsoundreflectingchangesinventricularcompliance,bestheardwiththebell
withthepatientinaleftlateraldecubitusposition.Itmaybepresentduringischemiaorinthesettingof
hypertension.
Identifytheseheartsounds.
[HEARTBEAT]
Mitralregurgitationisaholosystolicmurmurreflectingmitralvalvedilatation,bestheardattheapex
thatmayradiatetotheaxillaandlowerleftsternalborder.Itmayoccurwithtransientischemia.

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Assesscongestiveheartfailure(CHF)inpatientswithextensivemyocardialinfarctionthatcompromises
cardiacoutputduetodecreasedstrokevolumeorheartrate.Whichfindingsonthecardiacexamhave
thebestevidenceforcongestiveheartfailure?
Rales,anelevatedJVP,andanS3consistentlypredictheartfailure.
[HEARTBEAT]
S3isalowpitcheddiastolicsoundreflectingchangedventricularcompliance,bestheardwiththebell
withthepatientinaleftlateraldecubitusposition.
Palpatetheanklesforedema.

DiagnosticConsiderations
Listyourdiagnosticconsiderationsinorderofimportanceandexplainyourrationale.
Presspauseandlistyouranswers.Resumewhenyouarereadytoreceivefeedback.
Angina.Thiswomanhasstressinducednonexertionalchestpain.Recentevidenceshowsthatwomen
presentwithmoresubtlesymptomsofcardiovasculardisease.Shehascardiacriskfactorsof
hypertension,pastsmoking,preeclampsia,andfamilyhistory.
Panicattack.Shehadstressrelatedsymptomsandflashbackstotherecentdeathofherfatherinacar
accident.Shehassuggestiveanxiety,chestpain,anddiaphoresis.
GERD.Heralcoholintakehasrecentlyincreased.Shehassomerefluxsymptomsbuthersymptomsare
nottriggeredbymealsandshedoesnotreportheartburn.
Musculoskeletalchestwallpain.Thereisnohistoryofchestpaintriggeredbymovementoftheupper
torsoorrelatedexercise,andnonotationofchestwalltenderness.
Dissectingaorticaneurysm.Thereisnoasymmetryofbloodpressuresnotedandnohistoryofpain
shootingintotheneck,upthesideofthehead,orintotheback.

DiagnosticWorkup
List5nextstepsinyourdiagnosticworkup.
Presspauseandlistyouranswers.Resumewhenyouarereadytoreceivefeedback.
EKG.About80%ofpatientswithanacuteMIhaveaninitialEKGthatshowsevidenceofnewinfraction
orischemia,ifreadcorrectly.However,amongpatientsmistakenlydischargedfromtheemergency
department,upto50%havenormalornondiagnosticEKGfindings.
Stressecho.Thisisthetestofchoiceforwomenwithatypicalchestpain.Theechocardiographystress
testhasasensitivityof90%andspecificityof79%forwomen,and85%and96%formen.

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Consideratrialofaprotonpumpinhibitorfor46weeksforpossibleGERD.
Chestxraymaybehelpfultolookforwidenedmediastinum,whichcanbeevidenceofaorticdissection.
Behavioraltherapytolearnmanagementstrategiesforanxietyandpanicdisorder.

Summary
Insum,thisisa50yearoldschoolcounselorwiththreeepisodesofleftsubsternalchestpainoverthe
priortwoweeks,rated5to10inintensity,withassociatedsweatingandshortnessofbreath.
Thefirstepisodewasprecipitatedbyreadingaboutacarcrash,thecauseofherfathersrecentdeath.
Thepatienthadhypertensionduringpregnancyandabriefsmokinghistoryinher20s.
Thereisastrongfamilyhistoryofcoronaryarterydisease.Hermotherdiedofamyocardialinfarctionat
age62andherbrotherhadacoronarybypassatage48.
Thereisnohistoryofdiabetes.Herphysicalexaminationisunremarkableexceptforherbloodpressure
of150over95.
Thedifferentialdiagnosisincludesangina,especiallysuspectduetohersymptoms,historyof
hypertensionduringpregnancy,andfamilyhistory.Italsoincludespanicattack,GERD,musculoskeletal
chestpain,anddissectingaorticaneurysm.
ThediagnosticworkupincludesanEKG,stressecho,trialofaPPI,chestxray,andbehavioraltherapy.

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