10:30am. I'd already seen a few patients during the course of the morning and, as I glanced over the appointments to come, I saw that next in line was Jake. From the few details I had in front of me, he was 22, and consulting for a sports physical. I open the door of my consulting room and look around the waiting room. "Jake?" I call out. A guy with short dark hair, dressed in a t-shirt and cargo shorts stands up and comes towards me. "Hi Jake, come in and take a seat" I say to him.
As he entered the room, I started to make my first judgements. Average height, doesn't look overweight, what appears to be a fairly toned body - I don't expect to find anything too unexpected during the exam. I return to my desk and start to take some of Jake's history. Ex smoker, stopped a year ago, no family history of cancers, heart disease on fathers side. Jake tells me he's recently started training for triathlon event and before that did some light weight training. He wants to make sure that everythings OK before he steps up the pace in his training. I tell him to strip down to his underwear and jump on the scales. Once undressed, I see that he is a fairly lean guy, with the beginnings of a 6 pack and some muscle on his pecs. His torso is hairless with just a slight trail of hair below the belly button. His breathing appears fairly normal not too fast or too shallow. After weighting him, I tell him to sit on the side of the exam table. I strap the blood pressure cuff around his arm and proceed to take his bp. Everything normal so far! After I take his pulse at his wrist. Slightly high. Is he nervous? I put my hands around his thorax and ask him to take a deep breath. I guage his chest expansion and then proceed to auscultate his lungs. As an ex-smoker, maybe i'll find something interesting? "Just stand up for me and turn around while I listen to your lungs". Jake obliges. I slip the stethoscope into my ears and say "please take a deep slow breath each time I press the stethoscope to your back ok?" he nods. Moving the stethscope around his back, I notice one or two very faint crackles as Jake's chest rises and falls. Surely the left over's of his smoking days I think to myself. On the last breath, he coughs a little. I turn him round and listen over the front of his chest. Nothing major to report.
"Ok Jake, I'm going to listen to your heart now, breathe normally." I take the stethoscope and place it over the apex, move fairly rapidly to the pulmonic, and start edging my way down the left side of his sternum. His heart speeds up mildly with each inhale and slows as he exhales, the rate is steady, regular, but a little fast. I stop at the tricuspid and count his pulse. It's now at 95. Slightly odd for a guy training for a triathlon I think to myself. I slip the stethoscope over to the mitral area and listen for a little longer. Taking his pulse again, its now at 100 bpm. "Are you nervous?" I ask. "yeh, a bit!" came the reply! I remove the stethoscope and place two fingers over his apical impulse, the size and amplitude is good. My fingers pulse a little with each beat of his heart. I put the stethoscope back in my ears and repeat the exam with the bell. I ask Jake to sit. Listening with the diaphragm, I ask Jake to breathe in deeply, lean forward and exhale. No murmurs over the apex. Repeat the process. Over pulmonic a faint hint of a murmur, and down to mitral, nothing. His heart is too fast I think to myself. "Jake, take a deep breath in, and hold it, don't let it out until I say". Jake obeys. I move the stethscope back to the mitral area. His heart slows a little and appears to beat harder. The head of the stethoscope moves a little with each beat. I reajust the position with the rim pushing gently into the flesh immediately below his dark left nipple. I let him hold until i really feel he can't do it any more. "Ok breathe slowly out". As he breathes out, his heart races a little harder then suddenly slows. "once more" i tell him. This time, his heart speeds up a little before slowing down again. I make him hold for a full minute. After breathing out again, I listen intently trying to pick out any signs of a murmur but I hear nothing but the clear lub dub of his heart. I need to push is heart a little. A nice fast run should do it! I indicate the treadmill and ask Jake to run for 5 mins, telling him it's important to test his heart.
The run was interesting. Immediately after stopping the treadmill with Jake sitting on the table again I repeat the exam. Now his heart is at about 170 bpm and he's breathing heavily. I can't help but notice that his dark nipples have hardened as I watch his chest heaving as he's out of breath. His heart is slamming into the head of the stethoscope. I wonder if it can keep up the work! After about a minute, it starts to slow a little, however I'm hearing a distinct murmur. "breath in and exhale deeply and hold please" I say as i push Jake forward. The murmur is pronounced. Sitting up again, I make Jake lie flat. His abs tense with each breath and in between, his aorta is pusating in his stomach. "Do you feel ok?", "Yeh, he pants". His heart seems to be taking a while to slow. Five minutes have past and it's still not under 110. I continue to listen, the stethoscope pushed into his apex. Eventually, after maybe 8 or 9 minutes, his pulse slows to 95. I stop listening. In the end, the fit guy isn't so fit I think to myself.
"I'll sign you off jake for the training, but you need to start gently and build up your heart's strenght and performance."