Cardiovascular examination — a systolic murmur
PLAB 2 & PRES 3 · cardiology · medium · 10 minutes
Candidate brief
You are an FY2 doctor in a cardiology outpatient clinic. Mr David O'Connell, 71, has been referred by his GP because of breathlessness on exertion. The nurse has recorded: blood pressure 108/84 mmHg, pulse 76 beats per minute and regular, oxygen saturations 98% on air. Please perform a cardiovascular examination. Present your findings to the examiner, then discuss the likely diagnosis and your management plan.
What examiners look for
An examination station is marked on sequence and completeness first, diagnosis second. A smooth, systematic routine that ends with "to complete my examination I would…" scores even when the candidate is unsure of the murmur. Pulse character is the highest-yield sign in this station: slow-rising and small-volume points to aortic stenosis before the stethoscope comes out, and a collapsing pulse would have pointed the opposite way, to aortic regurgitation. A narrow pulse pressure (here 108/84) is a quiet severity clue candidates often walk past — the nurse's observations in the brief were telling them something. Radiation decides the argument. An ejection systolic murmur at the right upper sternal edge that radiates to the carotids is aortic stenosis until proven otherwise; one that radiates to the axilla is mitral regurgitation. Always listen in both places. A soft or absent aortic component of the second heart sound suggests a stiff, calcified valve that can no longer close crisply — a severity sign worth presenting explicitly. Symptoms grade urgency more than loudness does. Exertional breathlessness plus a presyncopal episode makes this symptomatic aortic stenosis, which carries a poor prognosis untreated and needs prompt specialist assessment — a murmur can be loud and mild, or quiet and severe, in a failing ventricle. The echocardiogram is the decisive investigation: it grades the valve area and gradient, and management flows from it. Examination raises and supports the diagnosis; it does not replace imaging. Close the station by answering the patient's actual questions — the operation question, the dog-walking question and the driving question — with honest uncertainty where the echo result is still needed.
Guideline references
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