I Can't Hear Any Heart Sounds!

Well, based on this opening title alone, if you are the candidate doing station 3 (cardiovascular) and you are stuck with this initial finding, what would you do next?

I attended a UK PACES course last year and this was one of the cases. We (in a group of 7) were instructed to auscultate the precordium of this patient by turns. I practically couldn't hear anything on the left! I immediately moved my stethoscope to the right. The patient smiled at me and said: "You're fast to pick this up. You'll pass." This indeed was a boost to my confidence during the real exam! ;)

The unifying diagnosis I would like to consider for this patient is Kartegener syndrome. My principle findings on cardiovascular examination is that she has dextrocardia. The apex beat is at the right 5th intercostal space. There is no murmur to suggest an intracardiac shunt. Clinically, she is not in cardiac failure and she is in sinus rhythm.

She has obvious finger clubbing and on auscultation of her chest, there are coarse crepitations at the bases which diminish following a cough. I would be keen to examine the abdomen to look for associated situs inversus.

Q: How would you like to investigate this patient?

A: I would do a plain chest radiograph to confirm dextrocardia and to look for features of bronchiectasis.

(Examiner:"Here you are.")

A: The cardiac silhouette falls on the right side and there are ample findings which are in keeping with bronchiectasis. There are cystic changes resembling a bunch of grapes on the lower zones. Tramline opacities are noted especially on the left base. However, the gastric bubble appears to be on the left side hence I think this patient doesn't have situs inversus to complete the syndrome.