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.
SUMMARY (DIAGNOSIS - ETIOLOGY - FUNCTION - COMPLICATION)
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.