Clinical Method is Interesting and Enjoyable

We had a very good teaching ward round with three final year students today. We went in to see an elderly gentleman who had been admitted with breathlessness and had been found to have abnormal liver function tests.
We began to examine the patient and when we looked at his tongue we saw multiple circinate ridges surrounding annular central areas of with loss of papillae. This was a condition the students had not seen before. It was a geographical tongue and did not need further investigation.
We looked at the neck and noticed that the jugular venous pressure was elevated to the angle of the jaw. The dominant wave was systolic and it was expansile laterally. We discussed the causes of this going into basic pathophysiology. An expansile systolic wave would indicate that both the pressure and volume in the right atrium increased during systole. This would mean that the tricuspid valve was not competent. Hence, at this point we had diagnosed that the patient had tricuspid regurgitation.
On palpation of the apex we noticed that the patient had a forceful thrusting apex beat. We discussed the causes of a thrusting apex beat and the next exercise was for one the students to palpate the radial pulse and answer whether the likely valvular lesion was aortic regurgitation or mitral regurgitation (ventricular septal defect was unlikely in view of the age, absence of a thrill, absence of cyanosis). As the patient did not have a large volume collapsing pulse the likely lesion was mitral regurgitation.
Immediately the student was asked to listen at the apex and confirm his diagnosis. He did hear a pan systolic murmur radiating to the axilla.
The next question was what the characteristics of the second heart sound would be. This was discussed and the students were able to work out that mitral valve disease would cause right heart failure if the patient had developed pulmonary hypertension in which case the second heart sound would be loud and single. We then discussed the pathophysiology of the loud second heart sound.
On further auscultation of the heart we also noted a third heart sound at the apex.
We then discussed the likely cause of the abnormal liver function tests and decided that it was most likely due to congestion of the liver as a result of right heart failure and tricuspid regurgitation. This is another important learning point; in a patient with hepatomegaly and abnormal liver function tests, always look for elevation of the jugular venous pressure!