CARDIOLOGY

Gabriel Habib, Sr., M.S., M.D., F.A.C.C., F.C.C.P., F.A.H.A.
Her blood pressure was on the low side. I felt her pulse in the carotid artery in her neck; it was weak, difficult  to detect. Unlike  the usual thumping carotid artery,  her pulse  rose only  reluctantly  to the examining  finger.  At  the  base  of  her  neck,  on  the  chest  wall,  there  was  an  easily  felt  shudder,  a rough vibration with each pulse, like a cat’s purr. When I listened to her heart,  . . . I heard a gruff,
harsh sound like the clearing of a throat.  . . . It was no great Oslerian feat of diagnosis on my part to suspect that she had severe aortic stenosis.
John Stone (1936–2008)
“The Long House Calls” from
In the Country of Hearts: Journeys in the Art of Medicine,  1990
PHYSICAL EXAMINATION

1. Explain normal splitting of the second heart sound (S2).
S2 is normally split into aortic (A2) and pulmonic (P2) components caused by the closing of the two respective valves. The degree of splitting varies with the respiratory cycle or physiologic splitting. With inspiration, the negative intrathoracic pressure leads to increased venous return to the right side of the heart and a decrease to the left side. The increased venous return to the right atrium (RA) causes P2 to occur slightly later and A2 to occur slightly earlier, leading to a widening of the S2 split. With expiration, the negative intrathoracic pressure is eliminated and A2 and P2 occur almost simultaneously. The largest contributor
to the physiologic third heart sound (S3) split is the respiratory variation in the timing of
the pulmonic closure sound.

MEDICAL CONSULTATION

Eric I. Rosenberg, M.D., M.S.P.H., F.A.C.P.

1.   Why do physicians request medical consultation?
& For assistance in making a diagnosis in a patient with symptoms and signs suggestive of an unknown disease or syndrome
& To obtain advice on specific disease management (such as diabetes or hypertension)
& To obtain a procedure usually performed by a subspecialist (e.g., coronary angiogram in a  patient with persistent angina)
& To evaluate a patient’s ability to safely undergo surgical procedures

2.  How can one assess the effectiveness of medical consultation?
& Is the consultation question answered?
& Does the patient benefit from disease improvement or promotion of better long-term health?
& Are the consultant’s recommendations actually implemented?

3.  What factors increase the likelihood that the consultant’s recommendations
    will be ignored  by the referring physician?

& Poor communication between the requesting physician and the consultant (occurring 12–24% of the time in some studies)
& Delayed response to the consultation request
& Failure to address the requesting physician’s key clinical question
& Prematurely ending the consultant’s involvement in the patient’s care
& Infrequent follow-up visits
Goldman L, Lee T, Rudd P: Ten commandments for effective consultation, Arch Intern Med  143:     1753–1755, 1983.

Horwitz RI, Henes CG, Horwitz SM: Developing strategies for improving the diagnostic and management efficacy of medical consultations, J Chronic Dis  36:213–218, 1983.