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Short Cases in Medicine
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Short cases in medicine,Cardiovascular system
Examination routine
Introduce yourself and take consent
Ensure adequate exposure and request for a Outline of CVS Examination
chaperone if neccessary General examination
Proper positioning of the patient at 45 degrees Pulse examination
Comment on the general appearance of the patient Blood pressure
especially whether he or she is dyspnoeic or ill Precordial examination
looking Inspection
Start with the general examination Palpation
Febrile/not
Auscultation
Marfanoid features
Lung bases
Conjunctivae for pallor
Central and peripheral cyanosis
Liver
Dental hygiene
Finger and toe clubbing
Peripheral stigmata of infective endocarditis
Ankle edema/ sacral edema
Then move on to the examination of the pulses. This is divided into arterial pulse examination
and examination of the jugular venous pulse
Arterial pulse examination
Start with the radial pulse and assess the rate and the rhythm
Look for the character of the pulse and examine for collapsing pulse
Examine the peripheral pulses quickly and then go on to look for radio-radial or radio-femoral
delay
Look at the neck for visible carotid pulses
Feel the carotid pulse and comment on the volume of the pulse
Examine the jugular venous pulse
Try to look for the waveform of the JVP and measure the height of the venous pressure in
centimeters
Offer to measure the blood pressure
Examine the precordium
Inspection
Look for any chest deformities
Surgical scars- especially midline sternotomy scars and left thoracotomy scars
Look for visible pulsations over the chest wall
Palpation
, Palpate for the apex beat and comment on the position of the apex beat and whether it is
displaced or not. Also comment on the character of the apex beat
Palpate for thrills over the precordium
Palpate for a left parasternal heave which is indicative of right ventricular hypertrophy
Look for a palpable 2nd heart sound in the pulmonary area which is suggestive of pulmonary
hypertension
Auscultation
Listen to the heart sounds first and comment on any abnormality
Auscultate in all 4 areas
Remember to demonstrate auscultation in the mitral area with the bell and the patient in the
left lateral position for the murmur of mitral stenosis.
Examine the patient seated and leaning forward with the breath held in expiration for the
murmur of aortic regurgitation
Listen for any murmur and describe the murmur based on the following points. Always
remember to show the examiner that you are timing the murmur by palpating the carotid
pulse (R side)
Systolic or diastolic
Further as pan systolic, mid systolic, early diastolic etc.
The location where the murmur is best heard
The grade of the murmur
Radiation of the murmur
The effect of respiration on the murmur (Remember that the intensity of all right sided murmurs
is increased with inspiration and the intensity of all left sided murmurs are increased with
expiration)
Examine the liver and lung bases for evidence of cardiac failure
Try to reach a diagnosis before auscultation. This is possible and is extremely helpful for those who are
not that good in auscultation. Study the following table.
, Mitral stenosis
What is the diagnosis?
Why do you say so? What are the
other lesions which could present
with similar clinical findings?
Remember that the lesions given below are
extremely rare and are never given for the exam.
But the above question is a very popular one.
Carey Coombs murmur in acute
rheumatic carditis
Austin flint murmur in severe aortic
regurgitation
Atrial myxoma
What is the most probable aetiology?
Mitral stenosis is almost always rheumatic in origin
How would you clinically determine the severity of the lesion from the findings
of the physical examination?
The following are some features which would indicate a severe lesion
Longer the murmur the more severe the stenosis
The gap between the second sound and the opening snap (a narrow gap would indicate severe
stenosis but the opposite is not true)
Evidence of complications
Atrial fibrillation
Pulmonary hypertension
What are the complications associated with mitral stenosis?
Left atrial dilatation and atrial fibrillation
Left atrial thrombus +/- systemic
embolization
Pulmonary hypertension
Tricuspid regurgitation
Right heart failure
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