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
Other signs: palpable pulsatile liver, sacral and peripheral oedema. Look for evidence of chronic lung disease as TR may be caused by cor pulmonale. 9 Tricuspid regurgitation Instruction This man has a murmur. Please examine his cardiovascular system. General features Comment on the patient’s general well-being and in particular if short of breath at rest or cyanosed. Look for previous scars on the chest and more widely over the skin for evidence of intravenous drug abuse. Cardiovascular examination Check for stigmata of endocarditis.
Pay attention to dental hygiene. In mitral stenosis (MS) the following may be seen. • Pulse: atrial fibrillation (AF) is very common in MS. • Signs of heart failure: elevated JVP and giant v waves due to secondary tricuspid incompetence (also hepatomegaly, ascites and ankle oedema). • Apex beat: tapping (palpable first heart sound) that is not displaced. • Parasternal heave: suggests pulmonary hypertension. • Heart sounds: the first is loud, then there is a loud pulmonary second sound and an opening snap followed by a mid-diastolic rumbling murmur (with presystolic accentuation if the patient is in sinus rhythm) localised to the apex and heard loudest in expiration with the patient in the left lateral position.
The murmur of MS may be difficult to hear, so be alert for clues prior to auscultation. If a patient in PACES is in AF and their face looks as though it has a malar flush, then MS is much more likely to be the diagnosis than it might be in routine clinical practice. Note that the murmur of MS is accentuated with exercise, but tachycardia may make it more difficult to hear. The presence of an opening snap suggests the mitral valve (MV) is still pliant. The closer the murmur is to the second heart sound, the more severe the stenosis.
Cardiology and respiratory medicine by Paul R Roberts; Stephen J Fowler; Royal College of Physicians of London. Education Department
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