You are asked to assess a 78 year old non-smoker admitted  with progressive exertional breathlessness. On examination,  he has a respiratory rate of 28/min. BP 100/70 mm Hg. The JVP is elevated 8 cm above the sternal angle. The apical impulse is thrusting in nature and localized to the 6th left intercostal space, lateral to the mid-axillary line. On auscultation, there is an ejection systolic murmur, which is heard over the left second intercostal space and conducted to the root of the neck. There were bibasal crackles on auscultation of the lungs.

a) What is the likely diagnosis of his cardiovascular condition?

b) List 4 clinical signs which may indicate that the nature of his condition is severe.

[Click here to toggle visibility of the answers]

College Answer

a)     What is the likely diagnosis of his cardiovascular condition?

Aortic stenosis

Mention of HOCM or subaortic stenosis ? 2.5 mark
Mention of any other valvular lesion should not score any marks for this question.

b) List 4 clinical signs which may indicate that the nature of his condition is severe.

  • Plateau pulse
  • Aortic thrill
  • S4
  • Paradoxical splitting of second heart sound
  • Length and the harshness of the murmur
  • LV failure – a late sign

Discussion

Talley and O'Connor have a fine list of signs, which one mgiht expect to see in severe aortic stenosis.

  • Delayed carotid upstroke
  • Diminished carotid pulse on palpation
  • Apical impulse sustained (pressure loaded)
  • Absent or decreased A2
  • S4 gallop
  • Late peaking murmur
  • Long murmur
  • Murmur radiates to the neck

References

References

Clinical Examination of the Critically Ill Patient, 3rd edition by L.I.G. Worthley - which can be ordered from our college here.

Clinical Examination: whatever edition, by Talley and O'Connor. Can be acquired any damn where.