Cardiac OSCE — Focused Encounter Run-Sheet

01 Opening & Preparation

Every station opens the same way. The chief complaint and vital signs are given to you on a separate form — read them before you enter.

• 1Reviews the chief complaint and vital signs on the form before entering the room
• 2Knocks, enters, and introduces self by name and role"Hello, I am [name], a physician assistant student. I will be taking care of you today."
• 3Confirms the patient's identityPatient identifying data is the one thing the “patient” will answer directly. Everything else comes from the facilitator.
• 4Performs hand hygiene
• 5States the purpose of the visit and obtains permission to proceed"I am going to ask you some questions about what brought you in, and then examine you. Is that all right?"
• 6Ensures patient comfort and privacy before beginning
• 7Interprets the vital signs out loudDo not just read them back. Say whether each is normal and what an abnormal one would mean for a cardiac complaint.

02 Focused History of Present Illness

Chest pain is the commonest stem, but the same structure works for palpitations, syncope or dyspnea.

The seven attributes, applied to the chief complaint

• 8Onset — when it began, and what the patient was doing
• 9Location — where it is, and whether the patient can point to it
• 10Duration — constant or intermittent, and how long each episode lasts
• 11Character — what it feels like, in the patient's own words
• 12Alleviating and aggravating factors — what makes it better, what makes it worse
• 13Radiation — whether it moves anywhere
• 14Severity — on a scale of one to tenAnchor the scale. The number is meaningless until you ask what a ten is for this patient.
• 15Temporal pattern — better or worse at any time of day, or with any activity

Associated symptoms — Cardiovascular

• 16Dyspnea — at rest or on exertion, and how much exertion it takes
• 17Orthopnea — how many pillows the patient sleeps on
• 18Paroxysmal nocturnal dyspnea — waking at night short of breath
• 19Palpitations — and whether they are regular or irregular
• 20Syncope or presyncope
• 21Lower extremity edema
• 22Claudication — leg pain with walking that resolves with rest
• 23Cough, and whether anything is produced
• 24Nausea, vomiting or diaphoresis with the painThese are the associated symptoms that raise the concern rather than lower it.
• 25Fever

03 Focused Review of Systems, Past Medical, Social & Family History

All of these are FOCUSED, not comprehensive. Ask what bears on this complaint and on your differential — that selection is itself part of what is being graded.

Focused review of systems

• 26Constitutional — fever, fatigue, weight change
• 27Respiratory — cough, hemoptysis, wheeze
• 28Gastrointestinal — reflux, epigastric painWorth asking explicitly, because it belongs on the chest-pain differential.
• 29Neurologic — focal weakness, visual change
• 30Denies symptoms outside the focused set, and says so out loud

Focused past medical history

• 31Prior episodes of the same problem, and what was done about them
• 32Chronic medical conditions
• 33Previous surgeries or procedures
• 34Hospitalizations

Medications and allergies

• 35Prescription medications, with dose and how long they have been taken
• 36Over-the-counter medications, supplements and herbal productsEasy to skip and easy to lose a point on. Ask it explicitly.
• 37Allergies, and the reaction to each“No known drug allergies” is an answer; “allergies?” with no follow-up is not.

Focused social history

• 38Tobacco use — current or past, and how much
• 39Alcohol and recreational drug use
• 40Occupation and relevant exposures
• 41Living situation and who is at home

Focused family history

• 42Conditions in first-degree relatives that bear on this complaint

Close the history

• 43Summarizes the history back to the patient and asks whether anything was missed"Let me make sure I have this right — [summary]. Is there anything else I should know?"
• 44Signals the transition to the examination and obtains permission"I would like to examine you now. Is that all right?"

04 Vital Signs, Risk Factors & General Survey

The cardiac risk factors are a graded part of the history, not an afterthought. Ask them as a set so none is dropped.

Vital signs

• 45Restates the vital signs and interprets each one
• 46Comments on blood pressure, heart rate and oxygen saturation specifically
• 47States that blood pressure would be checked in both arms if indicated

Cardiac risk factors

• 48Hypertension
• 49Hyperlipidemia
• 50Diabetes mellitus
• 51Tobacco use — current or past, and how much
• 52Family history of premature coronary artery disease
• 53Obesity and level of physical activity
• 54Prior cardiac events, procedures or stents

General survey

• 55Comments on distress, color, diaphoresis and work of breathing

05 Focused Physical Examination — Cardiovascular

Maneuvers from the PD1 Cardiovascular and Peripheral Vascular lab checksheets, reduced to what a focused cardiac station grades. The position change matters — do it early and say why.

General

• 56Performs hand hygiene before touching the patient
• 57Places the patient supine with the head elevated thirty degrees
• 58Stands on the correct side of the patient for handedness
• 59Performs a general survey — distress, color, work of breathing, diaphoresis
• 60Inspects the hands and nail beds for cyanosis and clubbing

Neck — jugular and carotid

• 61Inspects the anterior neck for jugular vein distention"I am inspecting the anterior neck for jugular vein distention."
• 62Inspects the carotid pulsesLooking for the upstroke, its amplitude and contour, and any visible thrill.
• 63Asks the patient to hold their breath for ten seconds and auscultates each carotid with the diaphragm and the bell
• 64Palpates each carotid in the lower third of the neck, one side at a timeOne at a time, always. Bilateral simultaneous carotid pressure is the error being watched for.

Inspection of the precordium

• 65Inspects the precordium for abnormal wall motion and the apical impulse, using tangential lighting

Palpation of the precordium — finger pads, for heaves and lifts

• 66Second intercostal space, right sternal border — Aortic
• 67Second intercostal space, left sternal border — Pulmonic
• 68Third intercostal space, left sternal border — Erb's point
• 69Fourth intercostal space, left sternal border — Tricuspid
• 70Fifth intercostal space, left midclavicular line — Mitral
• 71Notes the size and intensity of the apical impulse — should be a light tap
• 72Notes the location of the point of maximal impulseDisplaced laterally is the finding that matters.

Palpation of the precordium — ball of the hand, for thrills

• 73All five areas — aortic, pulmonic, Erb's point, tricuspid, mitral

Auscultation of the precordium — diaphragm and bell at each area

• 74Second intercostal space, right sternal border — Aortic
• 75Second intercostal space, left sternal border — Pulmonic
• 76Third intercostal space, left sternal border — Erb's point
• 77Fourth intercostal space, left sternal border — Tricuspid
• 78Fifth intercostal space, left midclavicular line — Mitral
• 79Verbalizes what is being listened for — rate, rhythm, intensity of the first and second heart sounds, systole, diastole, extra sounds, murmurs
• 80Describes any murmur found — timing, location, radiation, intensity, qualityTiming first. Systolic versus diastolic is the branch point of the whole differential.

Lung bases

• 81Auscultates the posterior lung bases bilaterally
• 82Verbalizes listening for cracklesA cardiac station that never listens to the lungs has skipped the finding that separates compensated from decompensated.

Peripheral vascular

• 83Inspects the extremities for size, symmetry and edema
• 84Inspects skin color, venous pattern, hair growth and any ulceration
• 85Palpates peripheral pulses bilaterally — brachial, radial, femoral, popliteal, posterior tibialis, dorsalis pedis
• 86Grades each pulse and comments on symmetry
• 87Assesses capillary refill in the upper and lower extremities
• 88Notes that color typically returns within two to three seconds
• 89Palpates for pitting edema over the tibia and ankles
• 90Grades any edema found and states how far up it extends

06 Differentials, Studies & Diagnosis

Spoken, not performed. This is the part that separates a strong station from a complete one, and it is where the small groups have been training you: every request needs a reason attached.

Differential diagnosis

• 91States a differential diagnosis out loudFor chest pain the differential must reach beyond the heart — pulmonary, gastrointestinal and musculoskeletal causes all belong on it.
• 92Includes the worst-case diagnosis that must be excluded, even if it is unlikely“What must be examined to rule out the worst-case scenario?” is one of the two questions that decide the scope of a focused encounter.
• 93Justifies each differential against a specific finding from the history or examination"[Diagnosis] is on my differential because of [finding], and against it is [finding]."

Laboratory and imaging studies

• 94States which studies would be ordered
• 95Justifies each one — why it is needed and what it would tell you about the patientThis is the exact standard the small groups apply: a facilitator will not release information until the justification is given.
• 96States which differential each study would rule in or rule out

Diagnosis

• 97States the working diagnosis
• 98States the evidence from this encounter that supports it

07 Treatment Plan & Patient Education

The plan is a graded component in its own right, and patient education is named explicitly in the station's component list — it is not optional garnish.

Treatment plan

• 99States immediate management if the presentation is acute
• 100States which medications would be started or adjusted
• 101Addresses risk factor modification — tobacco, diet, exercise, lipid and blood pressure control
• 102States what would prompt cardiology referral
• 103States red flags that would send the patient to the emergency department

Patient education

• 104Explains the diagnosis in plain language, without medical jargonAdapting style and content to the patient is a graded professional behavior.
• 105Explains what the treatment is and why it is being recommended
• 106States return precautions — what would bring the patient back sooner
• 107Confirms understanding and invites questions"What questions do you have for me?"

Closure

• 108States the follow-up interval
• 109Thanks the patient and closes the encounter
• 110Performs hand hygiene on the way out

08 One-Minute Case Presentation

Delivered at the end of the station. A well-organized vignette that describes the patient and the clinical problem — not the note read aloud.

• 111Opens with the past medical history and the chief complaint"This is a [age]-year-old [patient] with a history of [past medical history] presenting with [chief complaint]."
• 112Gives the pertinent positives from the history
• 113Gives the pertinent negatives from the historyNegatives carry as much weight as positives. They are how the listener sees what you ruled out.
• 114Gives the pertinent positives and negatives from the cardiovascular examination
• 115Presents mostly in the order the history was obtained and the examination performed
• 116States the differential
• 117States the studies and the diagnosis
• 118States the plan
• 119Delivers it without reading from notesReading works directly against helping the listener visualize the patient.
• 120Keeps it to about one minute