HOCM

 

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

 

The salient findings on examination were a mid-late systolic ejection murmur loudest at the left sternal edge, which increased with valsalva maneouvre, which is consistent with hypertrophic cardiomyopathy. There was a concurrent pansystolic murmur at the apex with radiation to the axilla, which may represent mitral regurgitation in the context of systolic anterior motion of the mitral valve.

 

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, or xanthelasma. 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 A-wave due to contraction against non-compliant ventricle).

 

The carotid pulse was jerky with a double carotid arterial impulse (bisferiens) in character.

 

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

 

On palpation, the apex beat was fifth intercostal space mid-clavicular line pressure loaded / with a double/triple impulse. There were/were not any palpable thrills (systolic thrill at lower left sternal edge). There was/was not a left parasternal heave.

 

On auscultation, as aforementioned, there was an ejection systolic murmur loudest at the lower left sternal edge, and radiated up the sternal edge but not to the carotids. It was louder with dynamic Valsalva and standing, but softer with hand grip/isometric exercise. There was an associated pansystolic murmur at the apex with radiation to the axilla. 

 

There was a normal first heart sound and second heart sound, with reversed splitting, with an additional 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 hypertrophic cardiomyopathy.

 

Other differentials include:

• Aortic stenosis

• Aortic stenosis with mitral regurgitation

• Aortic stenosis with Gallavardin’s phenomenon

• MVP - different character, location and presence of a click

• VSD - character, and maneuvers

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram

 

ECG:

• LVH and lateral ST segment and T-wave changes

• Deep Q waves

• Conduction defects

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