I've seen one CVS case today.

Diagnosis according to casepaper and ECHO were Severe MS + Mild MR + Severe PHT.

[35yrs female, lower socioeconomic class, asymptomatic before 10yrs, admitted in ward on 2nd july,2008.]

Can anyone reply here findings which i should look for in such case in hostory and examination?

I've taken history and exmaination briefly today..Check following details.

History:

[All complains for last 10yrs.]

Breathlessness on exertion and when admitted even on rest. now on exersion only.
No PND but orthopnea present.

White watery Cough for last 7 dayssimilar complain since last 10 yrs.
No blood in sputum. Chest pain while coughing.

Low grade fever for 7 days releived with medication.

Palpitation increased on exertion machine type sound described by
patient. [confusion in asking details of palpitation..she's saying she has palpition,continous 24hours for 10yrs but increased on exertion and less after medication. is it possible? ]

c/o epigastric pain also..any significance of this in this case???

[any other history shd i write acc. to this case in negative history?]


Past History:

H/o join pain and swelling in larger joints [knee and ankle] when pt. was of 10yrs..

no other significant past history.

[ no h/o injection everymonth before she admitted then how can i diagnose her as known case on RHD? she told since 10yr she had complains for which she was taking medications from doctor in her village but no monthly injection history..]

[which other past history is imp. and i shd write/ask in this case?]
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Family history:

No positive history [of commmon complains which we ask in all case]
[which family history is imp. and i shd write/ask in this case?]
=====================

Personal history:

Not significant
[if any significant history i shd look for in this case, reply]

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General Ex.

T normal

P 77/min [rhythem seems regular but force/volume increased for 3-4 beats and then decreased not similer throughout 1min.. how to write about this?interpretation in related to this case? which type of pulse i shd look for in this type of case?]

RR 20/min [seems abdominothorasic??? it shd be thoracoabdominal in female???? y abdominothorasic in this case??

BP 110/70 mmhg

pallor present

clubbing seems present..not sure

I've not examined as a whole. which other features i shd look for in general ex. in this case?

==================

Systemic examination:

CVS:

Inspection:

precordium no bulge/retraction.

apex beat visible in 6th ICS just lateral to midline [it was continuous 3-4cm medially..so how should i describe? diffuse??any other details for apexbeat i shd write in inspection?]

visible pulsations at left lateral para sternal region

VISIBLE PULSATIONS were in next in front of SCM, clear in lying down position not in sitting.. is it JVP? i will check for it tomorrow carefully..


which other things i shd look for for this kind of case?

=================

palpation:

same for apex beat.. i think it was tapping..can it be in this casE? m i right?

heave at lower left para sternal region.

carotid pulsations palpable..no thrill..

Which other things i should palpate/check for this case?
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percussion:

not done yet.. shd i do in this case?

i think nothing but cardiomegaly may be there..

===========

Auscultation:


S1 loud..

murmur at mitral and tricuspid area..

no murmur/abnormal sound at Pulmonary & aortic area.[ Then how can it be PHT?]

confusion in murmur.. i think it's early diastolic..in case paper it's written that SM at apex [grade 3/6] and ?DM at apex.

which kind of murmur shd be there acc. to this case?

which otherthings in auscultation i shd write/check in this casE?

According to my findings, what should be diagnosis? i'm not able to diagnose by this findings.. i've exmine properly in 1-2days and reply here..
==============

Reply to all questions plz..some confusion in this case..hope after your reply i'll get an idea.

Thanks.

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If U Think Ur Life Getting Necrosed,Ur Dreames Inflammed,Ur Thoughts Thrombosed,Then Try This Out.Spread D Neoplasia Of Love Around U.
V.H.SHAH

It should either dry or productive cough. If pulmonary edema then, pink frothy sputum. Haven't heard "White watery Cough".


Not relevant in this case.


She might be going for Atrial Fibrillation?!



Never mind, almost all cases of MS in India will have RF as its etiology.



H/O hypertension, DM, IHD, Inf. endocarditis prophylaxis, Stroke etc; bcoz of thromboembolic complication of AF.


I think its Irregularly irregular. I suspect, She is in AF.!?



Whatever....dont bother!


What about signs of Right heart failure?! She is having pul. HT!!
Look for signs of atherosclerosis. (Arcus seniles, Xanthylasma etc; )




Since you have mentioned, Pul. HT, there should be Rt. heart hypertropy. Look for any para sternal pulsations.


Are you sure of loud s1, i dont think so, bcoz of severe MS?!

You havnt mentioned about opening snap!!

You should get loud p2 (pul. HT)


You should hear MDM at apex, but in severe MS, you may not hear it. All other murmur you hear are functional murmur!!

severe MS---->left atrial enlargement----->MR(functional)



Cheers!!

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whitish and watery sputum exists [reff. OZA PN 66]
.patuent denied yellow colour and told white colour and was telling consistency was like spit[saliva]...
not sure causes..
==================

For fever i will add it in cough details. [associated with fever]

Is it ok?
==========
is it possible to have palpitation for last 10yrs and which is also continous though releived on rest and aggravated on exersion?

Well, are u sure is it due to AF? as it may be due to other causes..
============
And other thing, while taking hostory and examination, you don't know diagnosis beforehand.

have u tried to tell similer reason to your examiner ever?
==========
I think u love AF much. just kidding. :P
==========
Irregularly irregular? how can u say?
then when it's regularly irregular? actually i felt regularly irregular as rhythm was ok but force/volume was alternating increasing/decreasing after 3-4beats/5-6beats
========
yes.there is parasternal pulsatons..lower left parasternal..does this suggests PHT?
i think it shd be on rightside also..isn't it?
========

i'm not getting palpable p2 or loud p2. i'll try to hear same tomorrow carefully.

not able to hear OS too..
============

__________________





If U Think Ur Life Getting Necrosed,Ur Dreames Inflammed,Ur Thoughts Thrombosed,Then Try This Out.Spread D Neoplasia Of Love Around U.
V.H.SHAH

1) She may have other causes for her palpations but with 10 yr. hx. of valvular disease - she is likely to be in A. Fib.
2) I think that the low grade fever may be importance in this case as the underlying question is if her symptoms have been ongoing for 10 years then why is she seeking medical treatment now? She is an ideal candidate for infective endocarditis.
3) For the sputum, you can always say "Productive cough with white sputum"
4) For the exam portion, a statement on the pt's overall appearance would be helpful (i.e. does she appear comfortable, respiratory distress, mouth breathing/pursed lips, anxious,etc...)
5) How old is the Echo (I assume it was transthoracic)? Has the stenotic gradient increased? May need a TEE to better evaluate - would also be better to look for vegetations.

I've examined and no any signs of IE. so it's excluded.

bcz symptoms increased in severity and breathlessness even on rest when admitted.

And chronicity is classic for MS though 10yrs is more but most patuents came to doctor after 4-5yrs atleast in our country..

-For ECHO i've checked only diagnosis..i'll read whole report in details tomorrow.

__________________





If U Think Ur Life Getting Necrosed,Ur Dreames Inflammed,Ur Thoughts Thrombosed,Then Try This Out.Spread D Neoplasia Of Love Around U.
V.H.SHAH

hmmm, not a straight case.. I've read it once.. i'll do it again tonight with my books

In my place RF is not so common, and we dnt get many murmurs to listen to.. Great that you guys are having these cases..

By the way, Vitrag , that was a good h/o and examination!!

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unfortunately patient was dischaged before i examine again today and verify with our proffesor.
But i've examined again yeesterday..i think she was predisposed or having AF as there was irregularly irregular pulse, irregular apex beats, apex pulse deficit more than 10..

But i wasnt able to appreciate loud p2 [she has PHT too] and diastolic mummur [of ms] , i was able to appreciate only s1 followed pan systolic mummur at apex [in 5th and 6th ICS] and less clear s2.

I'll write case prioperly and scan it and post it l8r here.

__________________





If U Think Ur Life Getting Necrosed,Ur Dreames Inflammed,Ur Thoughts Thrombosed,Then Try This Out.Spread D Neoplasia Of Love Around U.
V.H.SHAH

Am i seeing AF inside the quotes?!

Lolz!

yes. Your eyes are normal.

__________________





If U Think Ur Life Getting Necrosed,Ur Dreames Inflammed,Ur Thoughts Thrombosed,Then Try This Out.Spread D Neoplasia Of Love Around U.
V.H.SHAH