MITRAL STENOSIS

A 55 YEAR OLD WITH PALPITATIONS AND CHEST PAIN 

I've been given this case data to solve in an attempt to understand and analyize the topic based on patient clinical data in order to develop competency in reading and comprehending clinical data related to the case and come up with a suitable diagnosis.

You can find the original case in the link below-

https://himabindu5.blogspot.com/2020/05/hello-everyone.html

FOLLOWING IS THE PROBLEM LIST ACCORDING TO PATIENT'S PRIORITY:

MAIN COMPLAINTS

1. Palpitations

2. Chest Pain

3. Shortness of breath

4. Bilateral Pedal Edema

5. Decreased Urine Output

EACH COMPLAINT IN DETAIL:

1.PALPITATIONS:

• Since 2 months

• Pounding character

• POSSIBLE CAUSES:

1. Cardiac causes:Mitral valve prolapse,pericarditis,congestive heart failure
2. Non-cardiac causes:Hyperthyroidism, hypoglycemia 

2.CHEST PAIN:

• Since 2 months

• On left side

• More on epigastrium

• Non-radiating type associated with the palpitations

• POSSIBLE CAUSES:

-Myocardial infarction

 

-Mitral stenosis

 

-Acid reflux (ruled out as there is no dry cough or bitter taste)

 

-Pulmonary embolism

  

3.SHORTNESS OF BREATH:

• Since 2 months

• Progressive in nature

• Present Status:Grade III-IV of dyspnea

• Associated symptoms:

•  Paroxysmal Noctural Dyspnea since 2 months--more since the last 10 days
• Wheeze on right side
• Coarse crepitations--more on right side than left side

• POSSIBLE CAUSES:

• Respiratory cause(COPD,Pneumonia) -- ruled out as there are no symptoms such as cough,cold or wheeze
• Anemia
• Renal cause --ruled out as there is no facial edema
• Heart failure

4.BILATERAL PEDAL EDEMA:

• Since 1 week

• Upto Ankle

• POSSIBLE CAUSES:

• Heart Failure
• Liver disease-- ruled out as there is no ascites 
• Malnutrition --ruled out as there is no abdominal distention
• Thyroid disorder --rare

5.DECREASED URINE OUTPUT:

• Since 1 week

• Took medication for this outside

• POSSIBLE CAUSES:

• Dehydration
• Kidney failure
• Heart failure--can lead to renal failure

No H/O fluid loss, fever/cough

PAST HISTORY:

• No similar complains in the past 
• Not a known case of HTN,Diabetes,EPILEPSY,CVA,CAD
• No history of rheumatic fever 

FAMILY HISTORY:

• No similar complaints in the family.
• No history of HTN, CAD, rheumatic heart disease, obesity, diabetes, sudden cardiac death.

PERSONAL HISTORY:

• Mixed diet
• Appetite and Sleep-decreased
• Bowel&bladder-decreased urine
• Addictions-none

GENERAL EXAMINATION:

• He is conscious,coherent and cooperative,moderately built and nourished
• Afebrile
• Mild Dehydration
• Pallor absent
• No Icterus,cyanosis,clubbing,lymphadenopathy
• Edema upto ankles 
• BP:110/70mmhg
• PR: feeble

ON EXAMINATION:

RESPIRATORY SYSTEM:

• dyspnoea-present (grade III-IV)
• wheeze-heard on right side
• trachea-central in position
• breath sounds- vesicular in nature, with coarse crepitations heard (right>left)

CVS:

• Pulse- 72bpm, feeble, irregularly irregular, condition of vessel normal, pulse defecit could not be elicited.

ON INSPECTION:

• Normal except back-slight kypohosis present

ON PALPATION:

• Mitral area:

-apex beat=changed, down and outward (in 6th intercostal space, in anterior axillary line)

-no thrills present

• Pulmonary area=normal
• Aortic area=normal
• Tricuspid area=loud S1 felt, no thrills
• No palpable pericardial rub,no tracheal tug.

ON AUSCULTATION:

• Cardiac rate=72bpm, irregularly irregular rhythm 
• Mitral area=loud S1 
• Tricuspid-loud S1
• Pulmonary area=splitting of S2-loud P2 component.

ON EXAMINATION OF NECK:

• No engorged veins
• Elevated jvp with larger "a" component
• Hepato-jugular reflex didnot elicit.

ABDOMEN: Normal

CNS: Normal

INVESTIGATIONS SHOWED:

LFT shows: 

• Elevated total and direct bilirubin

• Elevated SGOT and ALP levels

RFT shows:

• Elevated Urea
• Elevated Uric acid
• Elevated Calcium
• Elevated Phosphorus

Hemogram shows: Microcytic Hypochromic anemia with neutrophilia

HIV: non-reactive

Troponin:NEGATIVE

Chest X-Ray:

• Cardiomegaly
• Enlargement of right atrium, right ventricle, Left ventricle

ECG:

• Irregular rhythm
• Absent p waves
• Right axis deviation 
• ST elevation in V4 V5 aVR

2D ECHO:

    

• Calcified mitral valves

• Fish mouth appearance

ANATOMICAL LOCATION OF THE ROOT CAUSE:

Reference: https://www.grepmed.com/images/3141/palpitations-evaluation-cardiology-diagnosis-algorithm-ddxof

• The pulse was feeble and irregularly irregular and ECG pattern suggest that palpitations are due to CARDIAC CAUSE

• Shortness of breath(grade II-IV) is associated with paroxysmal nocturnal dyspnea, wheeze and coarse crepitations on right side which may be due to Pulmonary Edema

• Source(https://medlineplus.gov/ency/article/000140.htm)says--

"Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs."

• As in this case,the edema is associated with shortness of breath and the ECG findings suggest of pathology related to HEART causing pulmonary hypertension-- The anatomical site of pathology most probably seems to be the HEART.

• Points not in favour of respiratory pathology are: No cough/hemoptysis/expectoration.

•  According tohttps://www.medscape.com/answers/163062-86210/what-causes-nocturia-and-oliguria-in-heart-failure -- 

"Oliguria is a late finding in heart failure, and it is found in patients with markedly reduced cardiac output from severely reduced LV function."

• Oliguria indicates decreased blood supply to kidneys indicating CHRONIC HEART FAILURE.

WHERE IS THE DEFECT IN THE HEART??

• According to the symptoms and after the complete CVS examination, i am of the opinion that it could be a case of left heart failure.
• JVP is elevated with large 'a' component suggestive of Pulmonary Hypertension as a complication of left heart failure.

WHAT MIGHT BE THE CAUSE FOR LEFT HEART FAILURE:

• 2D ECHO findings of calcified mitral valves and fish mouth appearance are suggestive of MITRAL STENOSIS.

PHYSIOLOGICAL FUNCTIONAL DISABILITY:

According to my knowledge:

Created by: Shivani

ETIOPATHOGENESIS:

Source: https://www.ijccm.org/book/9789352701926/chapter/ch57

DIAGNOSIS:MITRAL STENOSIS with HEART FAILURE

TREATMENT:

PHARMACOLOGICAL:

• INJ.LASIX 2amp in 50ml NS @8mg/hr --diuretic to treat edema
• oxygenation to maintain spO2 above 95%
• nebulization with budecort 12th hourly
• strict I/O charting
• monitoring BP,PR hourly
• inj.amiodarone 300mg (2amp) at 6ml/hr for irregular beats
• inj.pantop 40mg/OD/iv --to prevent gatric irritation
• T. ecosprin 75mg/PO/OD-- antiplatelet action to prevent clots

NON-PHARMACOLOGICAL:

• fluid and salt restriction
• head end elevation

FUTHER TREATMENT SUGGESTED:

• Percutaneous balloon mitral valvuloplasty
• Mitral valve replacement
• Use of anticoagulants
• Beta blockers

REFERENCES:

• https://himabindu5.blogspot.com/2020/05/hello-everyone.html

•  https://www.grepmed.com/images/3141/palpitations-evaluation-cardiology-diagnosis-algorithm-ddxof

• https://www.ijccm.org/book/9789352701926/chapter/ch57

• https://www.medscape.com/answers/163062-86210/what-causes-nocturia-and-oliguria-in-heart-failure

• https://medlineplus.gov/ency/article/000140.htm

• Davidsons principles of medicine

• https://en.wikipedia.org/wiki/Valvular_heart_disease

ACTIVE LEARNING AND CONVERSATIONAL DECISION SUPPORT TO TREATING TEAM OF THIS CASE :

[5/29, 20:17] MBBS 2016 UG 3: In the 55 yrs patient

[5/29, 20:17] MBBS 2016 UG 3: All examination findings suggest left sided pathology of heart

[5/29, 20:18] MBBS 2016 UG 3: But the JVP suggests right sided pathology sir

[5/29, 20:18] MBBS 2016 UG 3: How is this even possible?

[5/29, 20:20] MBBS 2016 UG 3: Is it because of the pulmonary hypertension due to left heart failure causing right heart failure?

[5/29, 21:10] Post Residency PG1: Yes simple isn't it 🙂

[5/29, 21:11] MBBS 2016 UG 3: Yes sir

[5/29, 21:40] Post Residency PG1:

"Cardiomegaly

Enlargement of right atrium, right ventricle, Left ventricle"

What are features of left atrial enlargement in the chest X-ray?

[5/29, 21:49] MBBS 2016 UG 3: 

-Double contour sign

-2 right heart borders

-Straightening of the left heart border

-Smaller aortic knuckle

[5/29, 21:58] Post Residency PG1: Are these not present in the patient chest X-ray?

[5/29, 21:58] MBBS 2016 UG 3: They are present sir