CARDIOLOGY

ResponseAortic Stenosis 

• Mid systolic/ejection systolic murmur, Crescendo-decrescendo, radiates to carotids. If severe also has cracles/breathless/S4 
• Syncope and exertional dyspnoea suggest this would be severe AS 

Aortic Sclerosis 

• Mid systolic murmur, Crescendo-decrescendo, radiates to carotids as per AS 
• No clinical significance - incidental finding 

HOCM 

• Mid systolic murmur, crescendo-decrescendo, active manoeuvres to ddx it from AS 
• Like AS - if causing syncope this is significant 

MR 

• Pansystolic murmur so unlikely to be this but may be mistake. Acute MR due to papillary rupture can be ejection systolic, but pt would be in extremis 
• Like AS - associated findings would suggest this is severe 

ResponseAdmit under cardiology for inpatient workup eg TTE-. (or at the very least needs a cardiology consult while in ED and early followup arranged) 
Avoid nitrates / diuretics. 
rationale: 
Previously undiagnosed AS most likely, and clinically this would be severe given the syncope, dyspnoea and crackles. Needs identification of severity of AS, commencement of treatment and monitoring.

ResponseAortic stenosis
Mitral regurg, mitral regurgitation
Pulmonary stenosis
Tricuspid regurg
VSD
ASD
HOCM

ResponseSlow rising pulse
S4
Paradoxic splitting of the 2^nd heart sound
Aortic thrill
Length and harshness of murmur
LVH – displaced apex beat
LVF – late sign

ResponseSevere AS – vasodilators are relatively contraindicated
Cardiac output is preload dependent (Filling stiff thickened ventricle)
Nitrate drops preload provoking cardiovascular collapse – same problem with anaesthetic agents.