Cardiovascular PACES an examiner’s perspective

Some candidates examine the patients in a chaotic fashion and often continue with discussion along similar lines and thus often fail themselves. Other candidates may examine in a superficially competent manner with an obvious sense of purpose but appearances can be deceptive. During the following discussion (candidates are not supposed to talk to examiners during the physical examination) a proportion will reveal that superficial competence was merely an unthinking and insightless routine. Even candidates with an obvious sense of purpose can be unthinking during the subsequent discussion. For example the confident detection and declaration that there was a murmur is almost always followed by an examiner’s question “What investigations would you do?” Hardly any candidate states that to confirm the murmur a sonocardiogram would be necessary. Usually the candidates states one of two investigations. “An ECG.” An ECG may reveal secondary changes in heart muscle, dysrhythmias or metabolic problems but does not confirm or deny heart murmurs or heart valve pathology. “An Echocardiogram.” This will show heart valve pathology but again will not confirm or deny the presence of an audible heart murmur, even a Doppler echocardiogram will not do this as it gives information about flow, but not about turbulent flow that usually causes heart murmurs.
It was my impression that aortic valve murmurs (some were confirmed by sonocardiogram) are more easily heard over the right clavicle than over the carotid artery. I presume this was caused by the greater impact of turbulent blood flow on the convex curvature of the aortic arch near where the right subclavian artery branches off, whereas the blood flow upwards into the right and left carotid arteries is less turbulent. Is this correct I wonder and is my interpretation correct? In the spirit of Karl Popper I would welcome evidence that I was wrong!

Dr Philip Welsby,
Edinburgh.

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