Description
The patient was an elderly man who was seated comfortably
in bed. He was of average height and weight.
There was no abnormality detected on examination of his
head. There was no head nodding. There was no pallor, the palate was not high
arched and there was no pulsation of the uvula.
On examination of his hands, there was no clubbing,
Quincke’s sign was not detected and there were no peripheral stigmata of
infective endocarditis.
His pulse rate was 80 beats per minute and regular. The
pulse was of large volume and was collapsing in nature and it was also possible
to note a double upstroke in the pulse (Bisferiens pulse). There was no
radio-radial or radio-femoral delay.
There was no brachio-radial delay but the double upstroke
was better appreciated in the brachial pulse.
No abnormality was detectable in the neck. There was no
visible carotid pulsation. The JVP was not elevated and the trachea was in the
midline.
There was no chest deformity. The apex beat was in the 6th
left intercostal space about 2 cms lateral to the mind clavicular line. It was
thrusting in nature. There was no left parasternal heave, no palpable closure of
heart valves nor were there any thrills.
The first heart sound was of normal intensity; the second
heart sound was soft and single. No added sounds.
There was an ejection systolic murmur at the aortic area
that radiated into the neck and there was a blowing early diastolic murmur at
the left sternal edge.
No extra-cardiac sounds were heard, the lungs were clear.
On auscultation of the femoral pulse, a systolic and
diastolic bruit were audible when the femoral artery was lightly compressed with
the bell of the stethoscope.
Analysis
♥
On initial general examination and examination of the head there
is no clue to the diagnosis.
ª
On examination of the hands no clue to the diagnosis is obtained.
¨
Sinus rhythm would make it less likely that the mitral valve is
involved. Mitral valve disease is more likely to be associated with atrial
fibrillation (ACES for PACES Page 193).
Be careful here,
the rhythm may be normal due to treatment or the patient may not have developed
atrial fibrillation.
§
A large volume pulse that is collapsing in nature would point to
aortic regurgitation (ACES for PACES Page
193,194)
♥
A Bisferiens pulse would suggest the patient has mixed aortic
valve disease. (ACES
for PACES Page 194)
ª
The collapsing pulse suggests regurgitation is the dominant lesion
(ACES for PACES Page
221)
The diagnosis at the moment is mixed aortic valve disease
with dominant regurgitation
¨
The thrusting displaced apex beat suggests aortic regurgitation
(ACES for PACES Page 201,202)
§
The patient may also have co-existent mitral valve disease but the
absence of atrial fibrillation is against this.
♥
The soft second heart sound is in keeping with aortic stenosis
(ACES for PACES Page
206)
ª
The normal first heart sound makes it less likely that the mitral
valve is diseased (ACES
for PACES Page 205)
¨
The ejection systolic murmur in the aortic area radiating to the
neck is in keeping with aortic stenosis
(ACES for PACES Page
210,213)
§
The blowing early diastolic murmur at the left sternal edge is in
keeping with aortic regurgitation (ACES for PACES
Page 211)
♥
The bruits over the femoral artery are a very good indication that
the patient has significant aortic regurgitation
(ACES for PACES Page 224)
Diagnosis
ª
Mixed aortic valve disease
¨
Aortic stenosis and regurgitation
§
Dominant regurgitation
♥
The aetiology of mixed aortic valve disease is usually aortic
stenosis with incidental aortic regurgitation
(ACES for PACES Page 217)
ª
Bacterial endocarditis affecting a stenosed aortic valve is
unlikely on clinical grounds as there were no peripheral stigmata of bacterial
endocarditis (ACES
for PACES Page 188, 189,190)
Aortic stenosis
Aortic regurgitation
See KEYS to SUCCESS in Medicine page 113-117
