Examine this patient's pulse. You may be asked to do this in the medical section of ophthalmology. You are usually asked to do this after  you have elicited other ocular signs such as central or retinal artery occlusion; pale optic disc; thyroid eye  disease or subluxated lens.  When you examine the patient's pulse remember to note the rate, the regularity and the character. This should  not take more than 45 seconds. The three most common findings are: The patient has a pulse rate of ___ per minute (take the number of pulse over 15 to 30 seconds and  multiply by 4 or 2 respectively) which is irregular. The patient has atrial fibrillation. Note: digoxin can slow down pulse rate and make the irregular pulse less obvious.   The patient has a pulse rate of ___ per minute. The patient is tachycardic (if pulse rate is > 100 / minute. Feel the patient's hands for warmth and sweatiness which are common in hyperthyroidism.   The patient has a pulse rate of ___ per minute. The pulse has a collapsing character.  Return to the top

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Listen to this patient's carotid artery. There is a continuous murmur best heard with the stethoscope placed lateral to the thyroid cartilage (ie. near  the bifurcation of the carotid artery). Do not confuse the bruit with the ejection systolic murmur arising from the  aortic stenosis (the ejection murmur in aortic stenosis times in with the heart beat and diminishes as one move the  stethoscope up the carotid artery). Other examination: look for embolic phenomenon as in branch or central retinal artery occlusion (but more likely you have  found this sign before being asked to listen for the bruit). examine the opposite neck for any endarterectomy scar. Question: What are the endarterectomy trials? Answer There two large international randomized multicentre trials (European Carotid Surgery Trialist's Collaborative Group and North American Symptomatic Carotid Endarterectomy Trial Collaborators). The trials showed definite benefit of carotid endarterectomy in patients with severe carotid stenosis (>75%) and recent cerebrovascular symptoms in the carotid artery territory. Those with stenosis between 30 to 70% are of uncertain benefit and those with mild stenosis (<30%) should not be considered for surgical referral. Return to the top

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

'Examine the cardiovascular system of this patient' or 'Listen to this patient's heart' (The following heart sounds are the most likely to encounter in the final MRCOphth: mitral stenosis mitral incompetence aortic incompetence mechanical heart valve Note: You are unlikely to be given right-sided valvular disorders.)   Mitral stenosis There may be malar flush on the face. The pulse is irregularly irregular (this may be slow suggesting controlled atrial  fibrillation from digoxin). The patient may have central sternal scar (from open heart surgery) or valvectomy scar (below  the left breast). The apex beat is not displaced but has a tapping nature. On auscultation there is a loud first heart sound  and mid-diastolic murmur. The murmur is best heard with the patient lying on her left side and with the bell of the  stethoscope. The murmur may be preceded by an opening snap. Other feature: again mention you would like to look for evidence of ocular emboli there may be bruising due to the use of warfarin Question:  What is the main risk of cataract operation in a patient with mitral stenosis? Answer The main risk relates to the use of warfarin and it is best to avoid peribulbar or retrobulbar anaesthesia due to the risk of  orbital haematoma. The anaesthesia can either be topical or intracameral in co-operative patient or general anaesthesia. Subacute bacterial endocarditis is not a risk unlike dental or gastrointestinal procedure; therefore antibiotic cover is not  needed.       Mitral incompetence The patient has atrial fibrillation. There may be mid-sternal scar or valvectomy scar. The apex beat is displaced (mention how much with reference to the mid-clavicular line and the intercostal spaces). On auscultation, there is a pan-systolic  murmur with radiation to the axillae. Other features: listen for associated mid-diastolic murmur as the patient may have mixed mitral stenosis and incompetence look for embolic phenomenon.   Aortic incompetence / aortic root dilatation The patient has a collapsing pulse. There may be a mid-sternal scar from aortic valve repair.  On ausculatation, there is an early diastolic murmur (best heard with the patient sitting forward and listen with  the bell of the stethoscope). Other feature: this condition is associated with Marfan's syndrome, look for lens subluxation and other features of Marfan's  such as tall stature, kyphoscoliosis, arm span longer than height and high arch palate.   Mechanical heart valve The pulse may be collapsing (in leaking aortic valve) or in atrial fibrillation (mitral valve replacement). There is a mid-sternal  scar from open heart surgery.  In the case of aortic valve replacement, the first heart sound is normal followed by an ejection click, an ejection systolic flow  murmur and loud click at second heart sound. The second heart sound times with the upstroke of the carotid pulse. In the case of mitral replacement, there is a loud click in the first heart sound followed by a click in diastole. There may be mid-diastolic flow murmur. Other findings: clinical signs of embolism (eg. hemiplegia, visual field defect or relative afferent pupillary defect from central retinal  artery occlusion). look for evidence of Marfan's syndrome which is associated with aortic valve dysfunction.   Return to the top

 
 
 
 
 
 
 
 
 
 
 

Palpate this patient's temporal artery. The patient is likely to have giant cell arteritis. The temporal artery is prominent and tortuous but there is absent pulsation ( the pulse is best felt just above  the zygomatic arch).  Other signs to look for: scar from previous temporal artery biopsy which may be hidden under the hair look for pale optic disc and relative afferent pupillary defect which may suggest arteritic ischaemic  optic neuropathy look for any features of obesity, round face (moon face) and thin skin which suggest that the patient is  on long-term systemic steroid     Return to the top