Sunday, November 23, 2008

Cardiovascular Examination

We had another good case at the recently concluded MRCP PACES course conducted by IBC in Dubai.
The patient was a young child who looked small.
In a small child with a cardiovascular problem one should consider congenital heart disease or rheumatic heart disease (ACES for PACES page 178)
On examination of the pulse we noted sinus rhythm approximately 80 beats per minute, no abnormality in volume or character, all pulses equal and synchronous.
No abnormality in the head or neck.
On examination of the praecordium the apex appeared displaced and was thrusting in nature.
A thrusting apex suggests mitral regurgitation, aortic regurgitation or ventricular septal defect (ACES for PACES page 202)
The fact that the pulse was of normal volume and not collapsing would make aortic regurgitation unlikely.
The fact that the pulse was in sinus rhythm would make mitral valve disease unlikely.
As we were already suspecting congenital heart disease VSD would be very likely.
On further palpation of the praecordium, we felt a systolic thrill at the left sternal edge. This would fit in with our suspicion of VSD.
Auscultation confirmed a harsh pan systolic murmur at the left sternal edge with no radiation of the murmur confirming our diagnosis of VSD.
Lungs were clear
Ventricular Septal Defect
Sinus rhythm
No heart failure
No reversal of shunt

Monday, November 10, 2008

Respiratory Examination

We saw another good case at the Dubai MRCP PACES course run by IBC.
The patient was a young Asian male man who seemed of normal height and weight.
On examination of his head there was no abnormality. On examination of his hands, initial examination seemed to reveal no abnormality, but on using the method of dividing the hands into systems (see ACES for PACES) it became evident that there was a difference in size and shape of the two hands. The left hand was smaller and narrower than the right. This was a consequence of an earlier injury during childhood. It had no bearing on the diagnosis but it did reveal the importance of correct method in revealing clinical findings.
On examination of the neck we noted that the trachea was deviated to the left. This indicated either a lesion pulling from the left or pushing it from the right.
On examination of the chest we noted that there was asymmetry of the chest with some flattening of the right apex and we also noted reduced movement of the right hemithorax. This showed that the lesion was on the right hand side. A lesion pushing the trachea from the right side. As a pneumothorax was unlikely in the setting of a course, the most likely diagnosis was right sided pleural effusion.
The remainder of the examination was now much easier as it was only confirmation of the findings of right sided pleural effusion.
The findings were an increased respiratory rate, apex beat was difficult to palpate, decreased vocal fremitus and reduced respiratory movements confirmed by palpation. Stony dull percussion note at the right base and decreased breath sounds and vocal resonance. Aegophony was heard at the upper border of the effusion.
Right sided pleural effusion
Probably due to tuberculosis
Impaired respiratory function

Saturday, November 08, 2008

Cardiovascular examination

We saw a classic case at the recent Dubai PACES course conducted by IBC
The patient was a young man who looked fit and healthy.
His pulse rate was 80 beats per minute, regular rhythm. His JVP was not elevated, trachea midline. Apex was not displaced and normal in character. The first heart sound was loud. This was the first clue that there could be a valvular lesion and quite correctly the candidates thought that the patient may have mitral stenosis. The second hear sound was of normal intensity, suggesting that the patient had not developed pulmonary hypertension. There was a clear cut opening snap in keeping with mitral stenosis. There was the classic decrescendo mid-diastolic rumble heard just medial to the apex beat and there was pre-systolic accentuation of the murmur indicating vigorous left atrial contraction. The findings were accentuated by turning the patient to the left lateral position and by exercise.
Lungs were clear

Mitral stenosis
Sinus rhythm
No heart failure or pulmonary hypertension
Most likely as a consequence of rheumatic fever