General Script:

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Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a systolic/diastolic murmur loudest in the ____ region, which increased on inspiration/expiration and radiated to the _____, and was associated with peripheral/JVP findings, which I believe is consistent with diagnosis.

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____.

 

On examination of the face, there was no scleral icterus, conjunctival pallor, xanthelasma, Argyll Robertson pupils, or malar flush. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was normal character/slow anacrotic/plateau/small volume/collapsing/bisferiens in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat was fifth intercostal space mid-clavicular line / displaced / pressure loaded / volume loaded. There were/were not any palpable thrills. There was/was not a left parasternal heave.

 

On auscultation, as aforementioned, there was a systolic/diastolic murmur loudest in the ____, which increased on inspiration/expiration, and radiated to the _____. (If nil radiation, state there was no radiation to the axilla or carotids). There was/was not any change with dynamic Valsalva and isometric maneuvers.

 

There was a normal/soft/loud/single first and second heart sound, with physiological/fixed/reversed splitting, with no additional third or fourth heart sound/third/fourth heart sound.

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with ____. In terms of severity, the findings of ___ suggest mild/moderate/severe. In terms of the aetiology, ____. In terms of complications ____.

 

Other differentials include:

• This murmur, but I consider it less likely because ____

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram