Summary Video

Once again, we have demonstrated that using one’s bedside skills alone we can, not only make a diagnosis at the bedside, but we can assess severity.

We started out by simply taking the blood pressure and we found a very narrow pulse pressure and a low blood pressure. And then we felt the carotid arterial pulse and it was small. These findings confirm one another. That is, it made us suspect immediately that there was something occurring, such as low cardiac output or obstruction to blood flow.

Then we proceeded to evaluate the venous impulse in terms of the central venous pressure and the wave contour. The central venous pressure was elevated, telling us there was right-sided congestive heart failure. The venous wave form was very unusual, a big wave during systole. We knew that because we timed it against the carotid arterial pulse. Now, how does that occur? It occurs because there is tricuspid regurgitation, and when the right heart pumps and the tricuspid valve is regurgitant, or incompetent, you see that pressure pulse in the neck. It’s very impressive, coming up when the carotid impulse comes up.

Then we evaluated chest wall movement and lo-and-behold, we go to search for the apical impulse, and we don’t even find any. Why? Because in a patient with mitral stenosis you have a relatively small left ventricle and a big right ventricle, in this case, because of the pulmonary hypertension that occurred and that actually pushes the left ventricle back. It actually should have been named the “behind ventricle,” to begin with, and now this “in front ventricle,” the right ventricle, pushes it back and you can’t even feel it on the chest wall. Then we did feel the chest wall, and we noticed not just an impulse in the right ventricular area, if you will, the mid-lower left sternal edge, but actually, a dilated pulmonary artery impulse was being appreciated at the second left interspace. That was typical and consistent with pulmonary hypertension. Then at the lower left sternal edge, we felt the right ventricular impulse due to dilatation/hypertrophy of the ventricle and even a third heart sound. Again, demonstrating reduced contractility in the right heart, some pump failure in the right, and also flow from the tricuspid regurgitation back into the right ventricle during diastole, that palpable third heart sound.

And finally, we listened to the patient. The important areas, the left sternal edge, at the upper area and lower area, and the apex. At the upper left sternal edge, we heard an ejection sound, and that ejection sound told us yes, there is a dilated pulmonary artery here. It’s typical of pulmonary hypertension. And that loud [mimicking sounds], that loud pulmonary second sound again confirmed the pulmonary hypertension. We listened at the lower left sternal edge and we heard the murmur of tricuspid regurgitation increasing with inspiration, and diastolic events to confirm the severity of the tricuspid regurgitation. As the patient breathed in we heard [mimicking sounds], and then as she breathed out [mimicking sounds]. It told us tricuspid regurgitation and it told us it was severe. And then, finally, we confirmed this wonderful diagnosis at the apex. This wonderful diagnosis of mitral stenosis. Why wonderful? Because up ‘till that point, all we had was a patient with severe pulmonary hypertension. And the nicest cause of this really is something you can correct. And mitral stenosis is potentially correctible. Other causes of pulmonary hypertension have a much worse prognosis than something like mitral stenosis. So, we listened at the apex and what do we hear? [Sounds] A long diastolic rumble telling us this was severe mitral stenosis. An opening snap close to the second sound, telling us this was severe mitral stenosis. A loud first heart sound, again confirming the likelihood of mitral stenosis and, finally, we knew it was severe because of not only the long murmur, but the early nature of that opening snap. So, in summary, we have a patient with severe pulmonary hypertension, at first blush. When we first examined the patient, we found the diagnosis. Severe mitral stenosis with a pliable mitral valve.

Diagnosis and severity

The key to defining the diagnosis of mitral stenosis in our patient was the recognition of the classic apical distolic low-frequency murmur. We also defined the severity by the company it keeps, including the non-auscultatory elements of the bedside examination, and the auscultatory findings in areas other than the apex. By then, tuning in on each component of the acoustic events at the apex, we confirmed that the lesion was severe, as the opening snap was early and the murmur was long.