Under pressure

This week in Cardiology clinic I met a patient with who had been diagnosed with pulmonary hypertension. During his appointment we reviewed his echocardiogram, noting some tricuspid regurgitation, an elevated RVSP, and some other findings of note. As he and I read through the report, I began to imagine his heart - the right ventricle perhaps larger than most, after years of contracting against elevated pulmonary pressures. I thought back to maneuvers we were taught in Year 1 - feeling for things like thrills and heaves - as I rested my palm gently on his chest, finding a suggestive thump. I scanned his neck and ankles, and listened to his lungs for extra fluid before I went to review with my staff. Together she and I pushed my initial exam musings further, explicitly noting the pathophysiologic changes we expected to see in pulmonary hypertension - for example, considering the implications of a loud S2 - before returning to the examination room. At the bedside, we confirmed my initial findings, and tuned our ears carefully to characterize the quality of his second heart sound (which in fact, was quite prominent, even at the apex). On reflection, I was glad to have this opportunity to meet this patient, and develop my skills in bringing together (and making sense of) my history, exam, and investigations (in this case, echocardiogram) for pulmonary hypertension. It was incredibly helpful to then review my exam, describe my rationale for the different signs, and stretch my assessment further to look for other findings. Finally, I was glad to be able to practice honing my skills in detecting these findings, with feedback from my staff in real-time - I think this teaching will be very helpful in the coming month (and year) attending to other patients, and further refining my assessments.

-AS