What is the diagnosis in this patient and what is the severity? We just use an orderly bedside approach and we are going to be able to predict both of those things, diagnosis and severity with high confidence. We start out with something as simple as taking the blood pressure, pumped up that cuff, watched the sphygmomanometer, 160/35. Now that gives us a message, doesn’t it? We start thinking, this patient could have aortic regurgitation. This patient could have a patent ductus arteriosus or maybe even a peripheral av shunt. But we went on, we evaluated the carotid impulse. Not only was it rapid rising, not only did it have a rapid collapse, but it was bifid. There aren’t too many things that cause that kind of a pulse, most consistent with aortic regurgitation, but occasionally a similar pulse can be felt with some element of stenosis, and even with a patent ductus arteriosus in terms of at least the rapid upstroke and the collapse. And this was all confirmed when we felt the peripheral pulses – hyperdynamic, and then, that word – hyperdynamic is very important, because when we felt the apical impulse, oh sure, it was inferolaterally displaced and it was enlarged and that told us, gee, this is possibly a volume-loaded ventricle. But we said, wait a minute, a failing ventricle can also be inferolaterally displaced and enlarged. But then we felt it and it was so hyperdynamic, much more consistent with that volume or preload… the previous to systole load, such as you see in aortic regurgitation, mitral regurgitation, shunt lesions – that hyperdynamic lesion was really not all that consistent with a failing ventricle. And last, but not least, auscultation.

Auscultation was critical. Auscultation confirmed our diagnosis. We listened in the upper right sternal edge and what did we hear? We heard “shwi-koo,” “shwi-koo,” “shwi-koo.” That made us suspect – gee, did this patient have an element of aortic stenosis with a systolic murmur? But no, there’s a better explanation for that systolic murmur. We listen at the lower left sternal edge and that’s really where the diagnosis was – “lub-kooo,” “lub-kooo,” “lub-kooo,” “lub-kooo.” That’s the diastolic decrescendo murmur that says “I have aortic regurgitation.” We go back up and listen again at the upper right sternal edge. At least think out what we heard there, and now we realize that that murmur in early systole, that wasn’t aortic stenosis, it was short, crescendo-decrescendo, again, short. It’s flow back across the aortic valve. Blood first leaked into the left ventricle “lub-kooo,” and then it came out – a little bit of excess blood – “shwi-koo,” “shwi-koo,” – and that’s consistent with the arterial pulse and all the other findings. This is not aortic stenosis, no. It’s aortic regurgitation. So, not only murmur number 1 – aortic regurgitation – another murmur in systole – flow back across the valve.

Finally, we go to the apex. We listen, light pressure on the bell, and what do we hear? “lubdub-errr,” “lubdub-errr,” “lubdub-errr.” A little softening of S1 and that differential of that diastolic rumble. Well, there’s a lot of rules on how you tell one type of diastolic rumble from another, but first you’ve got to think of what are the possibilities. Is it mitral stenosis? These were not typical findings with a loud first sound and the opening snap, and so on, no. This was more of a mid diastolic, more brief rumble, and that kind you sometimes get it if you had mitral regurgitation with blood flowing back across the valve, and you’d hear “shh-bu-err.” But we didn’t hear any mitral regurgitation. Heh, and what we really heard was just another murmur of aortic regurgitation – pressure rising in the left ventricle as that valve sits there and the blood regurgitates through the valve. The pressure rise just sort of shoves the mitral valve closed and you hear a physiologic type of mitral stenosis. So we already have three murmurs for this disease – we have the diastolic decrescendo, the short systolic flow across the valve, and now the Austin-Flint rumble.

This is a patient with aortic regurgitation and this is a patient wherein the aortic regurgitation is severe, the latter reflected by the enlarged left ventricle, the very wide pulse pressure, and also the other events that we heard acoustically.