Cardiovascular examination – pansystolic murmur

Location: You are a junior doctor based in an outpatient clinic. You have been asked by your consultant to perform a full cardiovascular examination.

Patient: Pat Keyne, a 78 year old presenting to outpatient clinic

– Examine this patient’s cardiovascular system
– Talk through your examination whilst examining, stating any key positives and negatives
– After 6 minutes you will be asked a series of questions by the examiner

You are a 78 year old patient, Pat Keane, who has attended outpatient clinic. You are happy to be examined by the junior doctor.

After the candidate auscultates your heart, play this clip:

There is no other abnormal pathology to simulate.

Category Question
Consent Candidate appropriately introduced themselves with:
Full name
Clarifies who they are examining
Gains consent for examination

Examination introduction Examination introduction
Washes hands
Appropriate exposes patient
Positions patient correctly at 45 degrees

Inspection Inspection from end of bed
Observes patient from end of bed
Comments on general appearance (well/unwell)
Comments if they look comfortable, alert, breathless, pallored, cyanosed
Comments if oxygen, fluids or monitoring is in place

Peripheral examination Peripheral examination, comments examining for
Capillary refill time
Temperature normal
Finger clubbing
Splinter haemorrhages
Tendon xanthomata

Pulses Examines for pulses
Radial pulse rate and rhythm
Collapsing pulse – no marking point if candidate does not ask if any shoulder / doesn’t explain procedure
Radio-radial delay

Face Face examined for:
Malar flush
Corneal arcus
Conjunctival pallor
Central cyanosis

Neck Neck examined for:
Carotid pulse volume and character

Inspection Closer chest inspection for
Presence of cardiac devices

Palpation Palpation for:
Apex beat – 5th intercostal space, midclavicular line

Auscultation Auscultation, examiner prompt: “please explain to me the anatomical landmarks you are using as you examine the patient”
Auscultates whilst palpating carotid pulse
Aortic region (2nd right intercostal space)
Pulmonary region (2nd left intercostal space)
Tricuspid region (Left lower sternal edge i.e 4/5th intercostal space)
Apex region (Left 5th intercostal space mid-clavicular line)

Auscultation extended Auscultation heart sounds extended
Carotid auscultation
Patient rolled onto left hand side, listening over apex, at expiration
Patient sitting forwards, at third intercostal space left sternal edge

Auscultation - pathology photo_camera After the candidate finishes auscultation of the heart, play this clip and ask them to comment
Heart sounds one and two present
Presence of pansystolic murmur

Extra Auscultation extra-precordium
Auscultation of lung bases
Checks for sacral oedema
Checks for pitting oedema over shin

Finishing Finishing remarks
Invites patient to dress again
Re-washes hands
Offers to view observation chart (including BP, HR, O2 sat and T)

Question What is the diagnosis?
Pansystolic murmur
Mitral regurgitation (or tricuspid regurgitation)

Question How would you differentiate between mitral regurgitation and tricuspid regurgitation?
Tricuspid regurgitation is loudest at the lower left sternal edge; whereas, mitral regurgitation is loudest at the apex
Mitral regurgitation radiates the the axilla
Mitral regurgitation is louder on expiration (lEft-sided); tricuspid regurgitation is louder on inspiration (rIght-sided)

Question What are the causes of mitral regurgitation?
Papillary muscle dysfunction (post-MI)
Structural degeneration
Rheumatic heart disease
Congenital: marfans and ehlers-danlos
Dilated cardiomyopathy

Submit your answers to get your score.

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