By Paul R Roberts; Stephen J Fowler; Royal College of Physicians of London. Education Department
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Additional resources for Cardiology and respiratory medicine
Look carefully for surgical scars, remembering especially that the left thoracotomy scar of mitral valvotomy is easy to miss (especially in women, when it can be hidden under the fold of the breast). CAR_C01_CAR 12/15/10 10:43 Page 31 CARDIOLOGY: PACES STATIONS AND ACUTE SCENARIOS Cardiovascular examination Further discussion Check for stigmata of endocarditis. Pay attention to dental hygiene. Check if the patient is in atrial fibrillation. Look for signs of heart failure, particularly elevation of JVP and displacement of the apex.
Replacement of a prosthetic valve should only be considered in patients who are symptomatic with objective evidence of valve failure. It is a high-risk procedure and may not provide a better outcome than an expectant approach in both the elderly and those with significant comorbidity. 5 Pansystolic murmur Instruction This man has a murmur. Please examine his cardiovascular system. General features Comment on the patient’s general appearance and in particular if he appears short of breath at rest, cyanosed or has a phenotype suggesting a particular valvular abnormality, eg Marfan’s syndrome (this can be associated with mitral regurgitation as well as aortic regurgitation).
Lungs: are there basal crepitations? Remember that these are not specific for pulmonary oedema and cardiac failure. 28 Signs of pulmonary hypertension This is suggested by the following. • Raised JVP. • Left parasternal heave (palpable right ventricle). • Loud pulmonary component of the second heart sound. Also note whether one leg is much more swollen than the other, which might indicate deep venous thrombosis. Examination of the JVP • Do not finish your examination until you have found out where the JVP is.
Cardiology and respiratory medicine by Paul R Roberts; Stephen J Fowler; Royal College of Physicians of London. Education Department