History
- • Chest pain — SOCRATES, radiation, exertion
- • Dyspnoea (NYHA class), orthopnoea, PND
- • Palpitations, syncope, claudication
- • Risk factors: HTN, DM, dyslipidaemia, smoking, family history
Examination sequence
- • WIPE — wash, introduce, position 45°, expose chest
- • End-of-bed: comfort, breathlessness, GTN spray, O₂
- • Hands: temperature, clubbing, splinters, Osler/Janeway, tar staining
- • Pulse: rate, rhythm, character; radio-radial + radio-femoral delay
- • BP both arms, JVP at 45°, hepatojugular reflux
- • Face: malar flush, central cyanosis, xanthelasma, dental hygiene
- • Carotid: character + bruit
- • Praecordium: inspect scars/devices; palpate apex, heaves, thrills
- • Auscultate 4 areas + axilla + carotids; sit forward in expiration (AR), left lateral bell (MS)
- • Lung bases, sacral + pedal oedema, peripheral pulses
Positive findings
- • Displaced apex — LV dilatation
- • Loud P2, raised JVP, parasternal heave — pulmonary HTN
- • Pan-systolic murmur at apex radiating to axilla — MR
- • Ejection systolic at base radiating to carotids, slow-rising pulse — AS
Differentials
- • Murmur + AF + raised JVP → mitral valve disease
- • Aortic dissection if unequal BP / radio-radial delay
- • HF: bibasal crackles + raised JVP + S3 + oedema
Viva questions
Q. How do you differentiate AS from aortic sclerosis?
A. AS has slow-rising pulse, narrow pulse pressure, soft/absent S2, radiation to carotids; sclerosis has normal pulse and no radiation.
Q. What investigations follow?
A. ECG, CXR, FBC/U&E/troponin, BNP, TTE; consider coronary angiography.
Common mistakes
- • Forgetting to time murmurs with carotid pulse
- • Missing radio-femoral delay
- • Not examining the back / sacral oedema
