An example of how to analyse a case during the paces examination has been added to the forum.
This method of analysis will allow one to arrive at a diagnosis before competing examination and this will allow one to be ready to start answering questions immediately.
The patient was an elderly man of average height and weight lying propped up in bed. He appeared breathless. His skin was deeply tanned and there were small hypopigmented macules on his trunk.
On examination of his head there was no abnormality of size or shape. On examination of his nose there was flaring of his alae nasi. The conjunctivae were pale. There was no malar flush.
On examination of his hands, there was no change in size or shape, his nails were not clubbed and there were no splinter haemorrhages. He had palmar erythema. Pulse rate was 88 beats per minute, irregular in rhythm and volume. No collapse. No radio-radial or radio-femoral delay. No tremors were noted.
There was no abnormality detected on examination of his forearms or upper arms, the blood pressure was not checked.
On examination of his neck there was no swelling. There was a visible systolic pulsation reaching up to the ear lobe. This pulsation varied with respiration; diminishing on inspiration and increasing with expiration. It was palpable but the pulsation could be reduced by pressure at the root of the neck and there was hepato-jugular reflux. The carotids were normal and the trachea was in the midline.
On examination of the chest there was a midline sternotomy scar and bilateral gynaecomastia. The apex was at the 6th left intercostal space 2 cms lateral to the mid-clavicular line. The impulse was diffuse but closure of the first heart sound was palpable. There was no left parasternal heave and no thrills. No palpable closure of the second heart sound.
On auscultation, the heart rate was 88 beats per minute and irregular, there was a click coinciding with the first heart sound, a loud single second heart sound and an opening click in diastole. There was a soft, blowing pan-systolic murmur at the left sternal edge, no radiation of the murmur.
On examination of the back there was sacral oedema and bilateral basal crepitations
On examination of the abdomen the liver was enlarged four finger breadths and pulsatile.
He had bilateral ankle oedema. There were no scars.
♥ On initial approaching the patient one observes a well nourished individual who is breathless. Breathlessness in a patient in the cardiovascular station would most likely suggest heart failure. The fact that the patient is well nourished suggests that this is of relatively recent onset, as he has not developed cachexia. The tanned skin adds weight to this assumption, as this would indicate that he has been up and about and probably been on holiday recently. A patient with long standing heart failure would have been unlikely to undertake this. The hypopigmentation is of doubtful relevance here.
ª Flaring of the alae nasi confirms the initial impression of breathlessness and adds further weight to the impression that he has heart failure.
ª The pale conjunctiva suggests that he is anaemic. Now, this brings in another reason for his breathlessness or it may be the cause of decompensation of previous cardiac disease.
¨ Palmar erythema suggests liver dysfunction. In the cardiovascular station this would imply cardiac cirrhosis.
¨ The irregular pulse suggests the patient has atrial fibrillation. The presence of atrial fibrillation would suggest a lesion in the mitral valve causing left atrial dilatation.
§ On examining the neck one notices systolic pulsation. Systolic pulsation could be arterial or venous. Although it is palpable the fact that it varies with respiration, there is hepato-jugular reflux and it can be obliterated by pressure at the root of the neck suggests it is the JVP. As it is a systolic expansile pulsation it is probably a V wave and this suggests tricuspid regurgitation. The fact that it is palpable suggests high pressure in the right atrium and this would imply that the patient has pulmonary hypertension. This lends more support to our impression that the mitral valve is involved, as mitral valve disease with left atrial dilation would result in both atrial fibrillation and pulmonary hypertension.
At this stage of the examination the presumptive diagnosis is:
Mitral valve disease
Atrial fibrillation
Pulmonary hypertension
Tricuspid regurgitation
Anaemia
♥ On examination of the chest one notices the midline sternotomy scar. A quick glance at the legs shows there are no scars of vein harvesting this suggests a valve replacement operation and from the evidence we have gathered so far it is the mitral valve that has been replaced.
ª The presence of gynaecomastia suggests treatment with digoxin or spironolactone. The fact that he has well controlled atrial fibrillation and the impression of recent onset heart failure would imply that the drug being used is digoxin rather than spironolactone.
¨ The displaced apex adds weight to the diagnosis of heart failure. The fact that it is not thrusting makes it less likely to be due to a regurgitant aortic or mitral valve.
§ The palpable first heart sound adds weight to our impression that the mitral valve is at the root of the problem.
♥ The irregular heart rate confirms our impression of atrial fibrillation and the fact that there is no significant apex-radial deficit suggests the fibrillation is well controlled and supports our contention that the patient is on digoxin.
ª The click coinciding with the first heart sound supports a diagnosis of mitral valve replacement (prosthetic valve) and the opening click further supports this.
¨ The loud single P2 supports our impression that the patient has pulmonary hypertension.
§ The blowing pan systolic murmur at the left sternal edge supports our diagnosis of tricuspid regurgitation.
♥ Oedema and bibasal crepitations support our diagnosis of heart failure.
ª The enlarged pulsatile liver supports the diagnosis of tricuspid regurgitation and also lends support to the suggestion of cardiac cirrhosis.
