how to deal with a case in CVS station

1. CVS for MRCPCH Clinical
BY
DR MohammedAyad
MRCPCH

2. General rules
The aim of this presentation is how to interpret the signs you
have gathered from your examination .and not how
to examine or to do a full CVS examination .
I will not talk here about how to examine a case in CVS station
as this is easily done by watching the videos of clinical
examination which are on the youtube .
But I strongly recommend this one
https://www.youtube.com/watch?v=nq-pc0Ty2n4

3. CVS short case scheme
This scheme has 6 main questions so as to
reach a diagnosis or at least a DD
1- syndromic or not ?
2- water hammer pulse or not ?
3- cyanotic or not ?
4- carotid or suprasternal thrills or not?
5- scars or not ?
6- auscultation findings..

4. 1-Syndromic or not
Common syndromes in CVS station
1- TS ….. COA , rare AS , AR
2- DOWN $ …. AVSD or rare VSD ..
3- NOONAN $ … PS..
4- William’s $ … AS
5- MPS …. AR or MR..

6. 2-Water hammer pulse or Not?
Causes of WHP in the exam are AR and rarely
other causes as anemia..
If there is a WHP what shall I do ?
1- complete your examination as usual .
2- these findings increase the possibility of AR
Head nodding – no cyanosis – no clubbing –
hyperdynamic apex – lt middle sternal border
diastolic murmur ..

7. 3- these signs exclude AR
Cyanosis – scars – systolic murmurs ..
4- if your findings go with AR ask the examiner
to
•Auscultate the femoral arteries

8. 3-Cyanosis or Not ?
Cases of central cyanosis in the exam
1- cyanotic CHD mainly TOF..
2- Eisenmenger syndrome ..
TOFEISENMENGER $
Usually with a scarUsually no scars
Usually with murmurUsually no murmur
S2 usually singleS2 is very loud

9. 4-Carotid thrill or No?
AS is the only case in the exam with carotid
thrill and this diagnosis is augmented by the
ejection systolic murmur over A1 ..
AS rarely comes in the exam with no thrill but
with murmur ..
My exam case was AS with faint thrill ..

10. 5-Scars or No scars
1- median sternotomy
Usually complex CHD ..
but also may be used for correction of VSD in
Egypt ( my mock exam case ) ..
3-Rt lateral
thoracotomy
2-Lt lateral
thoracotomy
TOF repairCOA correction
PDA ligation
PA banding

12. 6-Auscultation findings
You should be systematic
1- localize the apex
2- auscultation orders
Apex then LLSB , then A2 then P then A1 then
axillae , neck and back
3- you should comment on
Heart sounds then murmurs ( full comment )
then additional sounds

13. Common Heart murmurs in the exam
DIASTOLICWITH
CYANOSIS
SYSTOLIC
ARTOFASD
VSD
PS
AS
MR

14. DD of common CVS murmurs
At APEX
A1
AS with ejection systolic murmur radiating to the
neck ..
Take care of William’s $
MSMR
DIASTOLIC
LOCALIZED
SYSTOLIC
RADIATING TO AXILLA
ACCENTUATED S1WEAK S1

15. LSB
P area
ASD and PS as above

16. Special situation
Lt lateral thoracotomy + DEXTROCARDIA
This would be
KARTAGNER $
NB .. NEVER to miss DEXTROCARDIA
SYNDROMES
You should offer to search for other signs of the
syndrome

17. How to differentiate
1- systolic VS diastolic murmur
PULSE
2- Ejection VS pan SYSTOLIC MURMURS
According to maximum intensity
ES usually at P and A area and never at apex ..
PAN systolic usually at APEX and LSB and never at A or P
areas
3- in AS
You should examine the femoral puLse to exclude COA ..

18. IMPORTANT discussion points
1- signs of moderate to large VSD
Soft murmur
Murmur of functional MS
Cardiomegally
Plethora
Eisenmenger $
2- indications of interventions in PS
Pressure gradient across the valve > 40 ..
RV Pressure > 60 mmHg..

19. 3- complications of TOF
STROKE
Cyanotic spells
4- management of cyanotic spells in TOF
Squatting position
O2
Morphia
BB

20. 5- prophylaxis against IE
Many debates but this is according to NICE
guidelines

21. 6- NEVER to miss Long acting Penicillin in
management of rheumatic heart disease ..
7- AS
Needs restriction of activities in most cases ..