Course/ Mock Exam Cases Drill (Part 2)

Verbal feedback from the the cardiovascular lecturers indicates that on the average, the candidates performance was quite satisfactory. Nonetheless, some cases were done poorly. I had to admit that some of the cardio cases in the course were considered rare, nonethess, I could bet to my bottom dollars that the registrar in-charge wouldn't hesitate to put them up for PACES if only they're readily available!

As I'd told a few of the candidates, rare cases tend to have a set of signs which is so classical that most examiners are fond of asking:)

And yes, I always believe that rare conditions rely heavily on us (physicians) to diagnose. After all, that's our duty as physicians right? Hence, we should be well prepared for that.


After finished examining the patient, gather your thoughts and face the music!

In summary, this gentleman has ample of signs to suggest the diagnosis of hypertrophic obstructive cardiomyopathy (HOCM). This is because he has a jerky peripheral pulse with a bifid carotid pulse. The apex beat has double impulses and it's not displaced. There is a grade 3 ejection systolic murmur best heard along the left lower sternal border which well accentuated by asking the patient to perform Valsalva maneuvers. There is no S3 or S4 gallop and there is no other signs to suggest cardiac failure.

I would ask for your permission to perform other dynamic maneuvers which would further support my diagnosis.

Examiner:"What dynamic maneuvers that you have in mind?"

I would ask this patient to change from standing stance to squatting position during my auscultation, paying particular attention to the intensity of the murmur. I would expect the murmur to be softer when he is in squatting position, and louder again when he's standing.

Examiner:"How would you investigate him?"

I would do a resting ECG first. I expect voltage-criteria left ventricular hyperthrophy to be evident on the ECG. There might be some secondary ST and T waves changes as well. I would reckon that a CXR in this most probably would be normal since during my examination, the apex beat is not displaced and hence I wouldn't expect cardiomegaly.

But really, an echocardiogram would clinch the diagnosis. Classical signs from echocardiogram would include asymmetrical septal hypertrophy (ASH) and systolic anterior motion (SAM) of the mitral valve.