Station Title & Timing

  • Station Title: Cardiovascular Assessment of a Suspected Heart Murmur
  • Total Duration: 10 minutes (2 mins reading time + 8 mins for the station)
  • Time Allocation: * Intro & Brief History: 1.5 minutes
    • Physical Examination: 5 minutes (Strict management required)
    • Findings & Management Plan: 1.5 minutes

Learning Objectives

  • Primary: Demonstrate a time-efficient cardiovascular examination including specialized maneuvers.
  • Secondary: Communicate negative clinical findings effectively and provide a rational explanation for a transient murmur.

Patient Profile

  • Name: Mr. Alex Thompson
  • Age: 32 years old
  • Gender: Male
  • Occupation: IT Consultant
  • Social History: Non-smoker, rare alcohol consumption. No illicit drug use.

Presenting Complaint

  • “My GP sent me here because he heard a heart murmur during my life insurance medical exam last week. I felt a bit sick that day, but I feel fine now.”

Contextual Information

  • HPC: Patient had a viral-like illness last week with a documented fever of 39.5°C. He had a dry cough and body aches but no chest pain or shortness of breath. The murmur was detected while he was febrile.
  • PMHx: Generally healthy. No history of rheumatic fever or congenital heart disease.
  • Medications: Nil.
  • Allergies: Penicillin (Anaphylaxis).

Exam Instructions

Candidate Instructions

  1. Introduce yourself to the patient and perform a brief, focused history.
  2. Perform a cardiovascular examination. Note: Specific maneuvers are required to exclude pathology.
  3. Explain your findings and proposed management plan to the patient.

Standardised Patient (SP) Instructions

  • Demeanor: You are slightly anxious about your insurance application but otherwise feel healthy.
  • The Trap: If the candidate asks you to lie down, lie completely flat. Only move to 45° if they specifically ask for it.
  • Key Information: If asked about last week, confirm you had a high fever.
  • Findings: You have no physical signs. If the candidate asks you to perform maneuvers (Valsalva, leaning forward), follow their instructions exactly.

Examiner Instructions

  • The Exam: If the candidate fails to position the patient at 45°, mark “Fail” for the Position component.
  • Clinical Signs: The patient is clinically normal (no murmurs). Observe if the candidate performs the “murmur maneuvers” (Left lateral, Valsalva, Leaning forward).

Key Clinical Findings

  • Vitals: BP 120/80 mmHg, Pulse 72 bpm (Regular), Temp 36.8°C.
  • Peripheral: No splinter hemorrhages, Osler’s nodes, or Janeway lesions. No clubbing or cyanosis.
  • Precordium: Apex beat may not be palpable (Normal variant). Heart sounds $S_1$ and $S_2$ are normal. No murmurs present.

Communication Triggers (Murtagh’s Approach)

  • Open-ended: “Tell me more about how you were feeling when the doctor heard the murmur.”
  • Clarification: “Just to be sure, have you ever been told you had heart issues as a child?”
  • Explanation: Use the term “Flow Murmur” or “Innocent Murmur” and explain it like “water rushing through a pipe more quickly than usual because of the fever.”

Assessment & Marking Guide

CriteriaKey Requirements
W.I.P.E.Wash hands, Introduce, Position at 45°, and Exposure.
Peripheral ExamAbbreviated (under 90s). Checked hands (O.J.S signs), pulse, and face.
Core ExamPalpated for heaves/thrills. Located apex beat (if possible).
AuscultationMandatory Maneuvers: Mitral (Left lateral), Tricuspid (Valsalva), Aortic (Leaning forward).
CommunicationClearly explained that no murmur was heard today.
Clinical ReasoningLinked the previous murmur to the fever (Hyperdynamic state).
ManagementSuggested an Echocardiogram for insurance “gold standard” clearance.

Sample Model Performance

The Explanation:

“Mr. Thompson, I have completed a thorough check of your heart today. The good news is that I cannot hear any murmur at all right now. When you saw your GP last week, you had a very high fever. A fever makes your heart beat faster and more strongly, which can create a ‘flow murmur’—essentially the sound of blood moving faster than usual. It is usually temporary and harmless. However, to ensure your heart structure is perfect for your insurance, I will refer you for an Echocardiogram (an ultrasound of the heart) to confirm everything is normal.”