Saturday, July 30, 2016

Mitral Stenosis

1. Wash hand, introduce, consent.

2. General inspection - malar flush? expose - scar?

3. Can I examine your hands please? Peripheral stigmata of IE. Finger clubbing.

4. Just going to feel your pulse. Rate, rhythm - AF?, volume and character. Feel the other side, and then femoral. Feel the brachial. Then collapsing pulse.

5. Could you look slightly to the left for me, just going to examine your neck. Look for JVP - systolic v wave. raised?

6. Could you look up for me, just going to check ur eye, and look to my finger down there? Pallor, jaundice.

7. Could you open your mouth and stick out your tongue, and up to the roof? Dentition and peripheral cyanosis.

8. Going to examine your chest. Look for the scar - mitral valvutomy, left lateral.

9. I am going to feel your heart beat. Feel for 1. Character - tapping S1. Displacement. The parasternal heave, and thrills of TR.

10. I am going to have a listen, and feel the neck at the same time. Apex diaphragm, S1 - loud? S2. Then opening snap? Early in diastole. Any murmur? Radiation to axilla. Now turn to bell. Mid diastolic murmur? Turn to left lateral.

11. Proceed with LLSE, LUSE, RUSE. If murmur then proceed for accentuation.

12. Lung bases and pedal oedema.

13. Cover up and thank the patient.



Ms X is not breathless at rest. There is no peripheral stigmata of IE. Her pulse rate is 80 beats per minute, irregularly irregular, but with normal volume. The JVP is not raised. There is no malar flush.


Moving on to the praecordium, there is no scar. Apex beat is tapping, undisplaced. There is no heaves or thrills. On ausculatation there is loud first heart sound, and normal second heart sound. There is an opening snap in early diastole. There is also a mid-diastolic murmur at the apex, 3/6 in grade and accentuated by left lateral position with breath hold in expiration. The lungs is clear and no pedal oedema.


In summary, Mrs X has a mitral stenosis with no signs of IE and not in failure. There is no sign of overwarfarinisation for the AF. The most likely etiology for MS in her is Rheumatic Fever. I would like to complete my examination by looking at the temperature chart, urine dipstick and measuring her blood pressure. Thank you.


Aortic Valve Replacement

1. Wash hand, introduce, consent

2. General inspection. Expose - median sternotomy scar. Breathless at rest? Corrigans? (so as to look hard for collapsing pulse later)

3. "Can I look at your hands please?" Peripheral stigmata of IE 

4. "Just going to feel for your pulse". Rate, regular/irregular, volume. Check the other side for radial radial delay. Check brachial pulse as well.

5. "Do you have any pain in the shoulder? Ok, I am going to lift it up above your head". Looking for collapsing pulse.

6. "Could you turn slightly to the left, just going to check the neck". Looking at JVP and carotids. Feel for the carotids. 

7. "Could you look up for me, just going to check your eye, and look down?" Check for anemia and jaundice.

8. "Could you open your mouth for me and stick out your tongue" - look using torch. Check dentition and central cyanosis.

9. "Just going to examine your chest now". Look hard for other scar - mid sternotomy scar, valvutomy scar, palpate for pacemaker.

10. "I am going to feel for your heart beat". Palpate for apex beat, then parasternal heaves and any thrills. Count ribs. Displaced - likely AR, undisplaced 5th intercostal space, midclavicular line - likely AS. 

11. "Just going to have a listen and feel the neck at the same time". Apex - diaphragm - check for S1 and S2 (look hard for prosthetic click - time with the carotids) Bell. LLSE - diaphragm. LUSE - diaphragm. Listen hard for Early Diastolic Murmur !! then RUSE - diaphragm. Likely to have a ESM at aortic area.

12. "I am going to listen to the neck, could you take a deep breath and hold it" - radiation for ESM to the carotids

13. Could you sit up for me, lean forward, and big breath in and out and hold it for a second? - listen hard to EDM again!

14. Listen to lungs, and check for pedal oedema.

15. look for bruises, and harvesting vein at the legs and radial.

16. Thank the patient, cover him up and wash hand.


. I would like to complete my examination by taking the BP of the patient, looking at his temperature chart and do a urine dipstick.

Mr X had undergone an aortic valve replacement for, most likely AS. 

There is no peripheral stigmata of IE. His pulse is 70 beats per minute, regular and normal volume. There is no collapsing pulse. JVP is not raised, and there is no conjunctiva pallor or jaundice.

On my examination of the praecordium, there is a midline sternotomy scar. Apex beat is not displaced. There is a normal first heart sound and a prosthetic click coincide with second heart sound. There is an ejection systolic murmur loudest at the aortic region, but no radiation to the carotids. I would grade it 3/6 with no palpable thrills. There is no early diastolic murmur or collapsing pulse to suggest valve failure, and lungs is clear with no pedal oedema to suggest cardiac failure.

In summary, this patient had an aortic valve replacement, most likely for AS secondary to degenerative calcifications or chronic rheumatic heart disease. There is no clinical evidence of valvular leakage, thrombosis or hemolytic anemia. There is also no signs of pulmonary hypertension or cardiac failure. There is no sign of IE or overanticoagulation