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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 1: Chest Pain
This video format is designed to help you prepare for objective structured clinical examinations, or OSCEs.
You are going to observe and participate in a clinical encounter of a patient who comes to the office with a complaint of chest pain.
As you observe the encounter, you will be asked to answer questions while the image on the screen freezes. Such questions will allow you to practice history taking and physical examination skills as well as your clinical reasoning skills in developing an assessment or differential diagnosis and a plan—that is, an appropriate next diagnostic workup.
You will have time to record your findings and receive feedback.
Health History
Tell me your special concerns today.
I’m a little worried because I have been having sharp pains in my chest for the last two weeks.
What findings might be important to look for as you observe this patient?
Level of distress.
Labored breathing.
Skin color: central and peripheral cyanosis.
Respiratory rate.
Two weeks ago I was reading a story in the paper about a car crash, when I noticed sharp pains in my left chest. I was sweating and short of breath for about 5 minutes. And my heart felt like it was racing.
What possible causes of chest pain are you considering?
Angina.
GERD.
Panic attack.
Musculoskeletal chest wall pain.
Can you tell me how severe the pain was, on a scale from 1 to 10, with 1 being very faint and 10 being severe?
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I was 5 over 10.
Did it move into your neck or down your left arm?
No, no it was just in my chest.
How have you been since then?
I’ve had two other episodes, one of them was about 10 days ago when I was lifting some books, the other was about 5 days ago when I was talking with my sister about our father’s death. He died 3 months ago in a car crash.
Did you have any other symptoms when you had these chest pains?
Yes, I had the same sweating and shortness of breath, with some light‐headedness during the most recent one.
What was the level of pain?
The same, about 5 out of 10 for about 5 minutes. Then the pain just went away while I was sitting there. I keep feeling so lost and panicked since my father died.
How are you feeling today?
Today I’m feeling fine, but I haven’t been sleeping well. It’s strange, I never felt anxious or depressed before.
What cardiovascular risk factors do you need to consider in this patient? And which one has the highest risk for coronary artery disease?
The risk factors are:
Family history of coronary artery disease.
Hyperlipidemia, hypertension, smoking, diabetes.
For women, preeclampsia and collagen vascular disease.
Family history conveys highest risk.
Do you have any problems with acid reflux? Or have you done any heavy lifting or strenuous exercise?
No, I’ve never had any stomach problems and I don’t really exercise much.
Do you have a history of high blood pressure? I noticed today your blood pressure was 140 over 95.
Yes, well I did have high blood pressure during my three pregnancies, I think it was about 145 over 90, but the deliveries were fine.
What about smoking?
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When I was in my 20s I smoked about a pack a day for about 4 years.
Do you drink any alcohol?
I have 1…or 2 glasses of wine maybe 3 nights a week, more recently to help me relax.
Is there any heart disease in your family?
Yes, my brother had bypass surgery when he was 48, and my mom died of a heart attack when she was 62.
What about high cholesterol, or is there any diabetes in the family?
No, I’ve never had trouble with my cholesterol and we don’t have diabetes in my family.
You’ve given me a good picture of your symptoms, and I can see why you’re concerned. Is there anything you think we may have missed?
No, but I can’t get away from these flashbacks about my father’s accident.
It’s common to visualize scenes like a crash with a loved one. Let’s do your physical examination, and then we can talk more.
Physical Examination
I see your blood pressure is 150 over 95 and your heart rate is 95 today. These are both somewhat elevated. I would like to begin by examining your lips and nails for color and then listen to your lungs.
Okay.
Examine lips and nails for cyanosis.
Okay, looks good.
Percuss then auscultate posterior lungs in ladder pattern.
Take a deep breath.
Listen to the lungs making sure to listen to the right middle lobe under axilla.
One more time.
[BREATHING IN AND OUT]
I’ll be examining the vessels in your neck, and then your heart. So please lie back with your feet straight out.
Examine the neck first.
Assess the jugular venous pressure.
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Find the highest point of oscillation in the internal jugular vein…
…and measure the vertical distance from the sternal angle.
Palpate carotid upstroke.
The normal upstroke is brisk, smooth, and rapid, and follows S1 almost immediately.
Large bounding upstrokes indicate aortic insufficiency.
Listen for a bruit, which is a whooshing, murmur‐like sound often from atherosclerotic narrowing of the carotid artery. A bruit sounds like this:
[BRUIT, WHOOSHING MURMUR]
Okay, I’m going to check the tapping impulse point of your heart.
Palpate the point of maximal impulse. You can do this and listen to the heart sounds by listening under the gown without exposing the chest.
You may notice “tapping” which is timed at the beginning of systole. The point of maximal impulse may be sustained or diffuse, meaning spread over more than one intercostal space.
Listen for S1 and S2 in each of the six listening areas: in the aortic area in the right second interspace close to the sternum; in the pulmonic area in the left second interspace close to the sternum; in the left third interspace; in the tricuspid area in the left fourth and left fifth interspaces; and in the mitral area at the apex.
Use the diaphragm at the right upper sternal border and the lower left sternal border.
Use the bell at the apex.
Listen to and palpate the abdomen.
The following findings may be heard in the cardiac auscultation of this patient. Can you identify these heart sounds?
[HEARTBEAT]
S4 is a low pitched diastolic sound reflecting changes in ventricular compliance, best heard with the bell with the patient in a left lateral decubitus position. It may be present during ischemia or in the setting of hypertension.
Identify these heart sounds.
[HEARTBEAT]
Mitral regurgitation is a holosystolic murmur reflecting mitral valve dilatation, best heard at the apex that may radiate to the axilla and lower left sternal border. It may occur with transient ischemia.
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Assess congestive heart failure (CHF) in patients with extensive myocardial infarction that compromises cardiac output due to decreased stroke volume or heart rate. Which findings on the cardiac exam have the best evidence for congestive heart failure?
Rales, an elevated JVP, and an S3 consistently predict heart failure.
[HEARTBEAT]
S3 is a low‐pitched diastolic sound reflecting changed ventricular compliance, best heard with the bell with the patient in a left lateral decubitus position.
Palpate the ankles for edema.
Diagnostic Considerations
List your diagnostic considerations in order of importance and explain your rationale.
Press pause and list your answers. Resume when you are ready to receive feedback.
Angina. This woman has stress‐induced non‐exertional chest pain. Recent evidence shows that women present with more subtle symptoms of cardiovascular disease. She has cardiac risk factors of hypertension, past smoking, preeclampsia, and family history.
Panic attack. She had stress related symptoms and flashbacks to the recent death of her father in a car accident. She has suggestive anxiety, chest pain, and diaphoresis.
GERD. Her alcohol intake has recently increased. She has some reflux symptoms but her symptoms are not triggered by meals and she does not report heartburn.
Musculoskeletal chest wall pain. There is no history of chest pain triggered by movement of the upper torso or related exercise, and no notation of chest wall tenderness.
Dissecting aortic aneurysm. There is no asymmetry of blood pressures noted and no history of pain shooting into the neck, up the side of the head, or into the back.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
EKG. About 80% of patients with an acute MI have an initial EKG that shows evidence of new infraction or ischemia, if read correctly. However, among patients mistakenly discharged from the emergency department, up to 50% have normal or non‐diagnostic EKG findings.
Stress echo. This is the test of choice for women with atypical chest pain. The echocardiography stress test has a sensitivity of 90% and specificity of 79% for women, and 85% and 96% for men.
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Consider a trial of a proton pump inhibitor for 4‐6 weeks for possible GERD.
Chest x‐ray may be helpful to look for widened mediastinum, which can be evidence of aortic dissection.
Behavioral therapy—to learn management strategies for anxiety and panic disorder.
Summary
In sum, this is a 50‐year old school counselor with three episodes of left substernal chest pain over the prior two weeks, rated 5 to 10 in intensity, with associated sweating and shortness of breath.
The first episode was precipitated by reading about a car crash, the cause of her father’s recent death. The patient had hypertension during pregnancy and a brief smoking history in her 20s.
There is a strong family history of coronary artery disease. Her mother died of a myocardial infarction at age 62 and her brother had a coronary bypass at age 48.
There is no history of diabetes. Her physical examination is unremarkable except for her blood pressure of 150 over 95.
The differential diagnosis includes angina, especially suspect due to her symptoms, history of hypertension during pregnancy, and family history. It also includes panic attack, GERD, musculoskeletal chest pain, and dissecting aortic aneurysm.
The diagnostic workup includes an EKG, stress echo, trial of a PPI, chest x‐ray, and behavioral therapy.
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