Cardiology Cases Answer Sheet Group ______________

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in ALL scenarios, you are requested to summarize the information you
obtained in the "history" (even if you didn't actually get it yourself, but
heard/read it) and THEN approach the patient for the physical examination.
Include identifying yourself, draping appropriately, "hand-washing" and
summarizing the information you have:
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:Communication Checklist for Student Feedback

Yes
Examinee knocked before entering
Appeared profession in dress/grooming/hygiene
Introduced self to patient.
Examiner identifies his/her role or position (DR).
Examiner asks or uses patient's name
Examiner makes comfortable eye contact
Focused attention & concentration on patient
Respectful & nonjudgmental attitude
Used transitional phrases and references
Used non-leading questions
Used one question at a time (clear and concise)
Used lay language (volunteered explanation)
Listened and paraphrased information throughout encounter
Examiner identifies patient's anxiety
Examiner expresses empathy and made appropriate reassurances
Summarized in closing and explained diagnostic plans
Placed patient at ease and communicated information without alarming the
patient
Asked if patient has any further questions and answered appropriately
On a scale of 1-6 how comfortable did you feel with this doctor?
1= uncomfortable
comfortable
Would you return to this doctor?

6=very

No

Cardiology Cases Answer Sheet Group ______________

Case 1:
Mr. Miller is a 42-year-old man in your office with newly detected blood pressure
elevation. He states he feels well and considers himself healthy. The nurse at
the plant where he works picked this up on a routine occupational health annual
check. She has checked him two additional times in the last month and each
time his BP has been elevated. He was referred to you.
His past medical history is remarkable for a kidney stone in 1995. He has NKDA,
is up to date on immunizations, and denies major adult illnesses.
Medications include Advil occasionally, high-dose multivitamins, and health food
store supplements. His dad is deceased of a MI (heart attack) at age 62, his
mother is living and in good health. One brother is without health problems.
Social: married with 2 children, he and his wife are in the process of divorcing,
smoked 1 ppd x 5 years, quit 15 years ago, drinks with the boys after work and
on weekends, quantifies as a couple of shooters and beers.
Here are some of the physical exam results already performed.
VS:
HR 82 RR 14 BP 168/92 RA sitting
General: sitting comfortably in the chair
Examiner: Please examine the Cardiovascular System as you deem
appropriate.
Observers: What additional physical exam maneuvers would you like to
perform on this patient to evaluate hypertension? Put your answers on the
answer sheet being specific about what you are looking for or examining.

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?I dont have anything to worry about do I

Case 2:
Please repeat the Cardiovascular Examination as in Case 1, using the
feedback Student 3 received to modify your performance.

Case 3
Ms. Smith is a 32-year-old woman who presents with chest pain intermittently
for two years. The pain almost stopped for a period of six months but it has
returned over the last 10 months. The pain is usually on the left side of the
chest, radiating to the left axilla. She describes it as a tight or gripping pain,
which lasts for anything from 5 to 30 minutes at a time. It can come on at any
time, often related to exercise but is has occurred at rest on some occasions.
The pain is usually associated with rapid breathing and shortness of breath. It
makes her stop whatever she is doing and she often feels faint or dizzy with
the pain. Occasionally palpitations come on before the start of the pain: she
describes the palpitations as a sensation of a strong but steady heartbeat.
Past medical history is remarkable only for abdominal pain 3 years ago that
was diagnosed as irritable bowel syndrome. These symptoms still trouble her.
Her grandfather died of an MI, her father had an MI at age 44, and there is a
strong family history of hypercholesterolemia. On routine physical 2 years ago
her cholesterol was 220 with low HDL. She works as a medical assistant, is
single, and lives alone.
Examiner: Please examine the Cardiovascular System as you deem
appropriate.
Observers: What additional physical exam maneuvers would you like to
perform on this patient to evaluate hypertension? Put your answers on the
answer sheet being specific about what you are looking for or examining.

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The doctors always tell me everything is because of my
nerves. Like my stomach problems.
Maybe this is too.

Case 4:
Please repeat the Cardiovascular Examination as in Case 3, using the
feedback Student 3 received to modify your performance.

Case 5
Mr. Miller, from Case 1, comes in for a routine hypertension follow-up appointment.
You had added Dyazide (a diuretic) 25 mg PO q D about 1 month ago for a BP of
168/92
You must first obtain an interval history of the time between his last appointment and
now.

Examiner: Please examine his chest.

Observers: Please comment on the examination performed by the examiner using
Professor Blieden's checklist

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.... .
Case 6
Ms. Smith, from Case 3, comes in for a routine follow-up appointment. She still
experiences occasional chest pain, which has been better since she started taking
aspirin and metoprolol daily. Her diagnosis was paroxysmal atrial fibrillation (a rapid
irregularly irregular heart rhythm).

Examiner: Please examine the pulses

Observers: Please comment on the examination performed by the examiner using
Professor Blieden's checklist

:
..... ,
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...." ".(metoprolol)

Case 7
Mr. Miller, from Case 1, comes in for a routine follow-up appointment. You had added
Dyazide 25 mg PO q D about 1 month ago for a BP of 168/92 , but now his BP is
90/60 and he complains of dizziness at times. He complains of occasional shortness
of breath.

Examiner: Please examine the Cardiovascular System as you deem

appropriate.
Observers: What additional physical exam maneuvers would you like to
perform on this patient to evaluate hypertension? Put your answers on the
answer sheet being specific about what you are looking for or examining.
Please comment on the examination performed by the examiner using
Professor Blieden's checklist

:
this" .
. "dizziness is really bothering me
I feel short of breath sometimes
......
Case 8
Ms. Smith, from Case 3, is brought to the ER by ambulance after having collapsed
and found to be unresponsive. She is conscious now but drowsy. You notice that she
is unable to move the left side of her body.

Examiner: Please examine the Cardiovascular System as you deem

appropriate.
Observers: What additional system would you like to perform on this patient
in order to evaluate her symptoms? What do you suppose caused her
presentation?
Please comment on the examination performed by the examiner using
Professor Blieden's checklist

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Case 9
Examiner: Please examine the Case 1 patient's heart sounds and relevant
abdominal examination

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Case 10
Examiner: Starting from the phrase Id like to perform a complete
examination of your heart and blood vessels , perform a complete
cardiovascular system examination.

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Professor Bliedens Checklist
Completed?
Student
1 2 3 4 5 6 7 8 9 1

AREA OF EXAMINATION

0
DISTRESS
CYANOSIS

Central (+ differential)
Peripheral

PALLOR
SKIN (additional)

FACE
SYNDROMES

HAND
Abnormal Fingers

PULSES
Character

Xanthomata
Telangiectasia
Lentigenes
Scleroderma
Butterfly rash (SLE)
Malar Flush (Mitral Stenosis)
Adenoma Sebaceum (Tuberous Sclerosis)
General Appearance
Marfan
(Ehler Danlos)
Down
Turner (Noonan)
Hurler
Hunter
Williams
Cyanosis
Clubbing
SBE
additional
long
short
(32 Syndromes)
Warm
Cold, Clammy
N.B. FEMORAL PULSE
Rate
Rhythm
Parvus-tardus
Bounding, Collpasing, Water Hammer
(17 causes including anemia, AO-PA

Shunts, Fever, Thyrotoxicosis,

Pegranancy & Other High Output
States)
Pulsus Paradoxius
Pulsus Alternans
CONGESTIVE
CARDIAC FAILURE

Peripheral Edema
Liver , Spleen
Anasarca
Crepitations

Lungs
CHEST

Inspection

Configuration

Palpation
Heaves

Pectus
Excavatum
Pectus
Carinatum
Scars
Thrills
Right
Left

PERCUSSION
AUSCULTATION
Murmurs

Systolic
Diastolic

S1 S2
Additional Sounds
Grade
Radiation

Learning Objectives
Cardiac Exam
1. identify and define the anatomical landmarks of cardiovascular system
2. Begin to develop an approach to performing a cardiovascular exam
3. Define the elements of the medical history that aid in identifying
abnormal conditions of the heart
4. Define the elements and physical exam components that aid in
identifying the abnormal conditions of heart
5. Define the character of the apical impulse with reference to anatomy
and ventricular function
6. Describe the events of systole and diastole as they pertain to the
cardiac cycle and heart sounds
7. Define and compare the differences of heart murmurs in systole and
diastole and the maneuvers to evaluate these murmurs
8. Define extra heart sounds in systole and diastole and causes of split
heart sounds
Peripheral Vascular Exam
1. Identify and define the anatomical landmarks of the peripheral vascular
system
2. Begin to develop an approach to performing a peripheral vascular
exam
3. Define the elements of the medical history that aid in identifying
abnormal conditions of the peripheral vascular system
4. Define the elements and physical exam components that aid in
identifying the abnormal conditions of the peripheral vascular system

5. Begin to differentiate between features of chronic arterial and venous

insufficiency
6. Define the different mechanisms and patterns of edema