We saw an interesting case today.
The trainee examined the patient and presented the findings and following this we went through the technique of cardiovascular examination in detail and analysed the findings.
We started off by having a general look at the patient and her surroundings. There was a yellow booklet by the bedside, which indicated that the patient was on warfarin. This immediately made us think of either an arrhythmia such as atrial fibrillation or a metallic heart valve.
The patient was a young female who was seated comfortably in bed. She was of average height but slim. Her skin was deeply tanned. I asked the trainee what the tan would mean and we concluded that this meant the patient was not unduly unwell and had been fit enough to go on holiday.
There was no marked abnormality on examination of the head although her palate seemed high arched.
There was no abnormality of her hands; her pulse rate was 80 beats per minute and regular, normal volume and character, no radio-radial or radio-femoral delay.
The fact that she was in sinus rhythm made us think she was on warfarin for a prosthetic valve.
There was no abnormality of her neck. In particular the JVP was not raised and the trachea was in the midline.
On examination of her chest a midline sternotomy scar was noted. The presence of the scar together with the fact that we had already noted the anticoagulation booklet made us think the patient had a prosthetic heart valve reinforcing the impression we had made by noting that she was in sinus rhythm.
The apex beat was in the 5th intercostal space just medial to the midclavicular line and the character was normal.
The heart rate was also 80 beats per minute and regular, dual rhythm.
The first heart sound was normal.
The second heart sound was replaced by a closing click of a prosthetic valve. This made us think that she had a prosthetic aortic valve. We listened carefully in systole and heard an opening click at the left sternal edge. Further evidence that she had a prosthetic aortic valve.
There was a soft systolic murmur at the aortic area, which was not conducted to the neck. Probably a flow murmur. No diastolic murmur was heard. No extra-cardiac sounds were heard.
There was no oedema and the lung bases were clear. However when we examined the patient’s back we noted a left sided thoracotomy scar
The trainee concluded that the patient had a prosthetic aortic valve, she was in sinus rhythm and that there was no evidence o heart failure. There was no valvular leak.
I asked him what the thoracotomy scar could be due to. One of our previous trainees who is now a registrar had a similar case when he went for the PACES examination and had been stumped by this question. The answer was easy for us and we were able to confirm that she had an earlier operation for repair of coarctation of the aorta.
I did include this in ACES for PACES page 201 so that candidates preparing for the MRCP PACES would be aware of such a possibility. The late complications of coarctation of the aorta include aortic valve disease because of associated bicuspid aortic valve.
One of the signs the trainee missed was the opening click. I know that this is one of the features that examiners at the PACES often question the candidates on and hence it is important not to miss it.
We went thorough the method of auscultation of the heart and reinforced the importance of heaving a robust method and sticking to it. Placing one’s stethoscope over the praecordium and listening to what one may hear is not enough. One must go through each phase of the cardiac cycle and analyse each component. (See ACES for PACES pages 165-169 summarised on page 170)
Another important point illustrated by the presentation of this case is the importance of a complete diagnosis. Replaced aortic valve, no leak, sinus rhythm, no heart failure, aetiology bicuspid aortic valve associated with coarctation of the aorta.
In other words the four components of diagnosis (ACES for PACES chapter 3)
