We had a doctor from another hospital attending PACES teaching for a few days. We wanted to show him how to approach a case in the exam and went through cardiovascular examination with him.
He started off as usual with a general examination and noted that the patient was seated up in bed, appeared breathless and had an oxygen mask on.
I asked him what he thought at this point, keeping in mind it was a patient with a known cardiovascular problem. He replied that he would say the patient had heart failure. (ACES for PACES page 177)
We asked him to carry on and he said he thought the patient was of average height and weight.
He next examined the patient’s hands. He went though in order and noted that the nails were normal, there were a few bruises on the skin, the bones, joints and tendons were normal but there was generalised wasting of the small muscles of both hands. I asked him why he thought the muscles were wasted and then he took a further look at the patient and said that he thought this was due to generalised wasting of muscles and that the patient looked emaciated. I asked him why the patient was emaciated reminding him that this was a patient with known cardiovascular disease. He replied that the most likely condition in the context of cardiovascular disease and heart failure was cardiac cachexia. (ACES for PACES page 179)
He next examined the pulse and said that the patient had a low volume pulse with several ectopic beats. I asked him what he thought the diagnosis was in a male patient in sinus rhythm (few ectopics) and a small volume pulse in a PACES simulation. (ACES for PACES page 190-195) He replied that the most likely diagnosis would be aortic stenosis. I reminded him that a diagnosis had more than one component and he then replied that the patient had aortic stenosis, was in heart failure and had cardiac cachexia.
On examination of the head the only abnormalities were flaring of the alae nasi in keeping with heart failure and a high arched palate.
On examination of the neck the JVP was not elevated and there were no other abnormalities.
On examination of the chest he noted a diffuse apex, soft 2nd heart sound and an ejection systolic murmur at the aortic area with radiation to the neck (ACES for PACES page 216-217)
There were basal crepitations.
We went through the findings again and reiterated how the diagnosis was made by the time he had finished examining the hands and that the remainder of the examination merely confirmed the suspicions that had been raised.
