|In the MRCOphth final, you may sometimes be asked to
examine the cardiovascular examination.
The ocular signs that often lead to a request for cardiovascular examination are:
expected to achieve the standard of a final year medical student. Therefore, it is worth revising
the steps needed for a complete cardiovascular examination.
Remember that there is no substitute to actually listening to a cardiac murmur in the medical ward.
The most common instructions are:
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visual field defect)
valvular replacement notably mitral valve for mitral stenosis is associated with
cardiac thrombus and retinal artery embolism)
retinal artery occlusion)
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.
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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).
- 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.
What are the endarterectomy trials?
'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:
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.
- again mention you would like to look for evidence of ocular emboli
- there may be bruising due to the use of warfarin
What is the main risk of cataract operation in a patient with mitral stenosis?
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
- look for any features of obesity, round face (moon face) and thin skin which suggest that the patient is
on long-term systemic steroid
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