Cardiovascular examination atrial fibrillation

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in out patient clinic, you have been asked by your consultant to perform a full cardiovascular examination for an admission clerking

Patient: 78 year old presenting to out patient clinic

– Examine this patients cardiovascular system
– Talk through your examination whilst examining, stating any key positives and negatives
– After 6 minutes you will be asked a series of questions by the examiner

Note to actor: Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 78 year old patient who has attended out patient clinic. You are happy to be examined by the junior doctor.

Abnormal findings: irregularly irregular pulse, HR 92. No other abnormal findings

BP = 125/70

At 6 minuets the candidate will be asked some questions by the examiner.

Category Question
Consent Candidate appropriately introduced themselves with:
Full name
Medical school
Year or grade
Clarifies who they are examining
Gains consent for examination

Examination introduction Examination introduction
Washes hands
Appropriately exposes patient
Positions patient correctly at 45 degrees

Inspection Inspection from end of bed
Observes patient from end of bed
Comments on general appearance (well / unwell)
Comments if oxygen, fluids or monitoring is in place
Comments if walking aids are present

Peripheral examination Peripheral examination, comments examining for
Capillary refill time
Temperature normal
Finger clubbing
Splinter hemorrhages
Tendon xanthomata

Pulses Examines for pulses
Radial pulse – if asked examiner states " Radial pulse is irregularly irregular"
Collapsing pulse – no marking point if candidate does not ask if any shoulder / doesn’t explain procedure
Radio-radial delay
Carotid pulse

Face Face examined for:
Malar flush
Corneal arcus
Conjunctival pallor
Central cyanosis

Inspection Closer inspection for
Presence of pacemaker
Midline sternotomy
Vein harvesting scar on legs

Palpation Palpation for
Apex beat – 5th intercostal space, midclavicular line

Auscultation Auscultation, examiner prompt: “please explain to me the anatomical landmarks you are using as you examine the patient”
Auscultates whilst palpating carotid pulse
Aortic region (2nd right intercostal space)
Pulmonary region (2nd left intercostal space)
Tricuspid region (Left lower sternal edge i.e 4/5th intercostal space)
Apex region (Left 5th intercostal space mid-clavicular line)
Examines all 4 regions with both bell and diaphragm

Auscultation extended Auscultation heart sounds extended
Carotid pulse auscultation, held at end expiration
Patient rolled onto left hand side, listening over apex, at expiration
Patient sitting forwards, leaning forwards, at expiration

Auscultation extra-precordium
Auscultation of lung bases
Checks for sacral oedema
Checks for calf tenderness and pitting oedema

Finishing Finishing remarks
Invites patient to dress again
Re-washes hands
Offers to view observation chart (including BP, HR, O2 sat and T)

This is the patients ECG. Comment on the key findings and give a most likely diagnosis

Irregularly irregular rhythm
Absence of P waves
Absence of an isoelectric baseline
Variable ventricular rate
Most likely diagnosis – atrial fibrillation

Question What are the causes of atrial fibrillation?
Ischaemic heart disease
Pneumonia / urosepsis
Rheumatic heart disease
Pulmonary embolus

Question What are the differentials for an irregularly irregular pulse?
Atrial fibrillation
Ventricular ectopic beats
Complete heart blocks with variable ventricular escapes

Question What scoring system is used to assess the risk of stroke for a patient in atrial fibrillation?