History, physical examination and clinical reasoning
The exam tests whether a focused history and bedside examination can generate a defensible pretest probability before any test is ordered. Vague answers about quality of life score poorly; precise symptom characterisation and named signs score well.
Symptoms that change management
- Chest pain: exertional, relieved within minutes by rest or nitrate suggests stable angina; pleuritic and positional suggests pericarditis; tearing pain radiating to the back suggests dissection.
- Dyspnoea: grade with NYHA class; ask specifically about orthopnoea, paroxysmal nocturnal dyspnoea and bendopnoea.
- Syncope: exertional syncope or syncope without prodrome is a red flag for aortic stenosis, HCM, long QT or catecholaminergic VT. Ask about family sudden death and injury.
Signs worth memorising
- JVP: normally up to 3-4 cm above the sternal angle. Cannon a waves with AV dissociation; absent a waves in atrial fibrillation; large v waves in tricuspid regurgitation; prominent y descent in constrictive pericarditis, blunted y in tamponade.
- Carotid pulse: slow-rising, low-volume in aortic stenosis; bisferiens in HCM or mixed aortic regurgitation; pulsus alternans in severe LV dysfunction; pulsus paradoxus above 10 mmHg in tamponade.
- Murmurs: ejection systolic radiating to carotids (aortic stenosis); pansystolic to axilla (mitral regurgitation); systolic murmur that loudens with Valsalva (HCM); early diastolic decrescendo (aortic regurgitation) with Austin Flint murmur.
Clinical reasoning
Frame a pretest probability, choose a test with a likelihood ratio that shifts you across a decision threshold, and state the management consequence.
Worked example
A 68-year-old reports exertional syncope and an ejection systolic murmur. The combination of syncope, slow carotid upstroke and radiating murmur makes severe aortic stenosis likely; echocardiography is the next step and symptom status drives intervention.
Traps
- Grading stenosis by murmur intensity: the murmur softens as ejection fraction falls.
- Mixing constrictive and tamponade JVP patterns.
- Accepting a single normal BP or a single troponin as definitive.