By using our bedside skills we have together made an elegant diagnosis. Elegant because we really went beyond diagnosis. Elegant because we have a tremendous confidence that we know the severity of this lesion and, in addition, we likely know the etiology. Now, we started out by a routine procedure, taking the blood pressure, and we found the blood pressure was a bit low, and the pulse pressure was narrow. That gave us an immediate clue, and when combined with the carotid arterial vessel that was small, that was slow in rising… that tells us: be alert, this may be a patient with outflow tract obstruction on the left side. Alternatively, we of course, must consider could this be a failing heart, a weak heart? But no, let’s go on and feel the chest wall and at the apex we feel that the location is right, but the size of the impulse is just “too big for normal,” meaning we likely have an hypertrophied ventricle. And that left ventricle further was telling us something. It was telling us that it was tough to get blood in there, because when we felt the impulse at the apex, the contour not only had a sustained systolic component, it had a presystolic component. And that means that that atrium, pushing blood into the ventricle finds the ventricle to be non-compliant, thickened, disallowing the normal velocity of flow into the ventricle, decelerating blood and having the presystolic impulse occur as a result. And, by the way, later we confirmed it on auscultation.
So then we went and we decided we would do auscultation at the upper right sternal edge, in the orderly fashion throughout the chest, but emphasizing first the upper right sternal edge. What did we hear at the upper right sternal edge? The classic crescendo-decrescendo systolic murmur that is late peaking of severe aortic stenosis.
When we went back and listened again, we heard an ejection sound. We not only know now that this is a patient with aortic stenosis. We know the level of it is at the valve. It is very likely that that ejection sound reflects a doming of a bicuspid valve, a congenitally bicuspid valve. And that ejection sound is a great clue then to etiology. We not only know diagnosis, severity, etiology: this is likely a bicuspid valve.
And then we went to the apex. What did we hear at the apex? We heard a fourth sound. That fourth sound was the same as the presystolic impulse we felt earlier. And we also found something rather interesting besides the fourth sound, we found out that that ejection sound which was so tough to hear at the upper right sternal edge, was darned easy to hear, relatively, at the apex, because by then the murmur that is going up in this direction [pointing up], had been filtered out to a degree and its intensity reduced.
So, in summary, we have with bedside skills alone evaluated this patient. We know the diagnosis, it is aortic stenosis. We know the severity, it is severe. And we know the etiology, it is a congenitally bicuspid aortic valve.