My CVS Station

Right after the neurology station, it’s time to move on to CVS station. While rubbing my hands with the septic gel, I read the instruction… which I can’t really remember.

I started of with the usual manner.. adequate exposure by asking the patient to remove his shirt. He was already lying down in semi-recumbent position but with a pillow behind his back.. I wasn’t sure if the bed could be reclined and thought it was okay, I left it as it is. General examination was like the usual and I saw a median sternotomy scar.. is this a good or bad??? By checking the pulse I detected that he has atrial fibrillation with good rate-control. JVP wasn’t elevated. Time to go to the chest… click.. click… I could very well hear the metal click! Again.. is this good or bad? At this point… I know that this gentleman has had valvular heart disease with AF and the valve has been replaced. Most likely a mitral valve disease. So my task was to confirm it and look for any other valvular heart lesion or any other valves that have been replaced as well. Also to look for any complications ie: valvular leakage, heart failure, infective endocarditis, evidence of overwarfarinazation.
Coming the chest, I was hoping for an easily palpable apex beat.. but NOT! I struggled to feel for the apex beat.. what my friend who has just passed his PACES in June 2009 said echoed… “Do not create signs.. show them your effort, including taking a little bit of time to look for apex beat”. So that was what I did…. By the time I took out my stethoscope to auscultate the heart sounds, the lead examiner reminded me that I had 1 MINUTE to complete my examination. Panic.. Panic! I tried my very best there… until I didn’t’ have much time to auscultate the carotids, and this case… very important! what I could gather is that,

“ Mr X is in atrial fibrillation with the rate controlled at 80 bpm. He is not in respiratory distress. He is not cyanosed or jaundice. He has no peripheral sign of infective endocarditis. The venous pressure not elevated. He has a well-healed median sternotomy scar with audible click. I had difficulty locating the apex beat and is displaced. The first and second heart sounds are metallic in quality. He has a systolic murmur at the aortic area. There is no pan-systolic murmur at the mitral area to suggest mitral valve leak and there is no early-diastolc mumur to suggest aortic valve leakage. He has no pedal oedema and no evidence to suggest over-warfarinization. So in conclusion I think Mr X has atrial fibrillation currently in good rate-control with both aortic and mitral valve replacement. Currently he is not in failure, no evidence of valvular leakage, infective endocarditis and over-warfarinization”

Then, he asked if I think that both the valves were replaced with bioprosthesis or metallic? There I thought I might be wrong in either one of it.. but I was certain about the metallic one!

He asked me if I could hear any radiation to the carotids… again! I honestly told him, I didn’t have time to check for it. Given more time, I would do so.

Further questions were about the management of the patient.

His final question was.. what would my advise be regarding exercise and the type of jobs that he can do… I got confused there as I couldn’t really link my diagnoses with the question.. and I gave a very general answer and kringgggggg!! SAVED OR UNSAVED by the bell!

Time to relax for 5 minutes. I know I didn't do well in this station!