Case wise Active learning and discussion-6
Case 6-- Mitral Stenosis
A 55 YEAR OLD WITH PALPITATIONS AND CHEST PAIN
We the MBBS final year students have been given these cases on weekly basis to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
- Link to Reference:
- Link to my analysis:
ACTIVE LEARNING AND CONVERSATIONAL DECISION SUPPORT TO TREATING TEAM OF THIS CASE :
- My active learning discussion:
[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
In comments section:
Sir...did the patient have pericardial effusion...
then what was the colour of the fluid on pericardial tap sir??
- OTHER DISCUSSIONS:
[25/05, 9:34 PM] Shravani Reddy: https://himabindu5.blogspot.
In this case.. dyspnoea classified under which classification mam?
[25/05, 9:57 PM] MBBS 2015 Intern 1: It’s classified under NYHA classification
[25/05, 10:17 PM] Shravani Reddy: Ma'am....in this patient is there no icterus??
[25/05, 10:18 PM] MBBS 2015 Intern 1: Nope..
[25/05, 10:19 PM] Shravani Reddy: Ma'am....But higher levels of bilirubin is seen?
[26/05, 1:27 AM] MBBS 2015 Intern 1: It wasn’t visible clinically
[26/05, 8:12 AM] Shravani Reddy: Chest pain on the left side more on epigastrium...
Ma'am, it indicates epigastrium pain or epigastrium pulsations?
[26/05, 8:48 AM] MBBS 2015 Intern 1: Epigastric pain
[26/05, 8:59 AM] Shravani Reddy: Ma'am....Chest pain and epigastric pain started at the same time ??
[26/05, 9:13 AM] MBBS 2015 Intern 1: No noo
[26/05, 9:14 AM] MBBS 2015 Intern 1: It’s the chest pain which is more in the epigastric area
[26/05, 9:22 AM] Shravani Reddy: Ok ...thank you, ma'am
[26/05, 10:17 AM] MBBS 2015 Intern 1: She has pain in the epigastric area. it’s one of the common presentations in inferior wall mi.. so to rule out that we got troponin I test done
[26/05, 10:20 AM] Shravani Reddy: Yes mam...troponin I test is negative
[26/05, 10:21 AM] Shravani Reddy: Mam...Pulse is irregularly irregular, absent p wave on ECG ....it indicates atrial fibrillation ??
[26/05, 10:23 AM] MBBS 2015 Intern 1: Yes
[26/05, 10:23 AM] MBBS 2015 Intern 1: She had paroxysmal af’s
[26/05, 10:24 AM] Shravani Reddy: Etiology of this patient ??
[26/05, 10:25 AM] Shravani Reddy: Any infection, aging?
[26/05, 10:25 AM] MBBS 2015 Intern 1: Idiopathic
[26/05, 10:26 AM] MBBS 2015 Intern 1: Basically MS is almost always due to rheumatic fever
[26/05, 10:26 AM] MBBS 2015 Intern 1: But she didn’t have any history
[26/05, 10:26 AM] Shravani Reddy: Yes mam
In the group:
[5/29, 22:07] MBBS 2016 UG 3: http://shivani2401elogbookmedicine.blogspot.com/2020/05/a-55-year-old-with-palpitations-and.html
Question:
How does elevated total bilirubin as in this case affect the outcome of cardiovascular diseases like heart failure?
[5/29, 22:10] MBBS 2016 UG Student 22: Heart failure might have caused liver dysfunction leading to raised bilirubin levels
[5/29, 22:16] MBBS 2016 UG 3: What is the effect of higher bilirubin levels on the risk of causing heart failure in those people?
[5/29, 22:23] MBBS 2016 UG 3: The question is effect of elevated total bilirubin on risk of heart failure...not vice versa
[5/29, 22:27] MBBS 2016 UG Student 22: This study shows there is inverse relationship between them
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/1471-2261-12-16
[5/29, 22:28] MBBS 2016 UG 3: Yes
[5/29, 22:28] MBBS 2016 UG 3: Even this source says it-https://www.google.com/amp/s/www.medicalnewstoday.com/amp/articles/321874
[5/29, 22:29] MBBS 2016 UG 3: 👍
[5/29, 22:30] MBBS 2016 UG Student 22: But in this case he has elevated bilirubin how does that explain his heart failure
[5/29, 22:30] MBBS 2016 UG 3: Yes
[5/29, 22:30] MBBS 2016 UG 3: But why?
[5/29, 22:33] MBBS 2016 UG Student 14: Okay, the thing is what u said was right but heart failure itself might cause increased levels of bilirubin
[5/29, 22:33] MBBS 2016 UG Student 22: Yes
[5/29, 22:33] MBBS 2016 UG 3: Yes...it can👍
[5/29, 22:33] MBBS 2016 UG Student 14: Heart failure can rob your liver of the blood it needs to work. The fluid buildup that comes with it puts extra pressure on the portal vein, which brings blood to your liver. This can scar the organ to the point where it doesn't work as well as it should.
[5/29, 22:34] MBBS 2016 UG 3: Maybe this is the reason for elevated bilirubin in this case then...
[5/29, 22:35] MBBS 2016 UG Student 14: Maybe
[5/29, 23:05] MBBS 2016 UG Student 17: Yes.. heart failure can cause liver failure which causes raised bilirubin... But is the patient having the heart failure of the severity that is required to cause liver failure to cause increased bilirubin levels...?
[5/29, 23:08] MBBS 2016 UG Student 2: His apex bear is displaced that means he has a chronic heart failure
[5/29, 23:10] MBBS 2016 UG Student 22: Then he should have severe MS
[5/29, 23:10] MBBS 2016 UG Student 2: We don’t know the surface area of Mitral valve right?
[5/29, 23:12] MBBS 2016 UG Student 13: Don't we need to know where the apex is displaced? Outward only or downward and outward? That'll tell us which ventricle is effected
[5/29, 23:13] MBBS 2016 UG Student 22: Down and out
[5/29, 23:13] MBBS 2016 UG Student 2: It’s displaced outward and downward and is in the anterior axillary line
[5/29, 23:13] MBBS 2016 UG Student 13: So left ventricle hypertrophy
[5/29, 23:13] MBBS 2016 UG Student 22: Seen in 6 Th intercostal space in ant axillary line
[5/29, 23:13] MBBS 2016 UG 3: Its downward n outwards as given in the case report
[5/29, 23:13] MBBS 2016 UG 3: Yes
[5/30, 09:30] Post Residency PG1: Have they mentioned the type of cardiovascular disease that are at lower risk with bilirubin at higher limits of normal?
Does the question apply to our patient who had bilirubin much higher than normal?
[5/30, 09:52] Post Residency PG1: Or left ventricular dilatation?
[5/30, 09:53] Post Residency PG1: Which ventricle?
[5/30, 09:55] Post Residency PG1: What does apex displacement have to do with severity of Mitral Stenosis?
[5/30, 09:55] Post Residency PG1: Chronic left ventricular failure gives rise to left ventricular dilatation? Why?
[5/30, 09:58] Post Residency PG1: Good question.
So what are the indicators to severe heart failure in this patient? Does she have right ventricular failure alone or also has left ventricular failure? Does left ventricular failure happen in pure mitral stenosis?
[5/30, 09:58] MBBS 2016 UG Student 22: No sir I meant is it severe MS leading to chronic heart failure which affected the liver also
[5/30, 10:00] Post Residency PG1: Severe pure MS causes which sided heart failure?
[5/30, 10:00] MBBS 2016 UG Student 22: Initially left sided failure and later even right heart failure
[5/30, 10:03] MBBS 2016 UG Student 20: I think it's initially right sided failure
[5/30, 10:03] MBBS 2016 UG Student 22: How?
[5/30, 10:05] MBBS 2016 UG Student 22: Mitral stenosis leads increase in left atrial pressure which leads in increase in pressure in pulmonary veins and a artery and right ventricle
Leading to right ventricular failure
[5/30, 10:05] MBBS 2016 UG Student 20: Initially left atrial pressure is increased to maintain thecardiac output which increases pulmaru capillary wedge pressure and resulting pulmonary HTN leads to right heart failure
[5/30, 10:05] MBBS 2016 UG Student 20: Yes
[5/30, 10:06] Post Residency PG1: Good discussion above 👍👏👏
[5/30, 10:07] MBBS 2016 UG Student 22: In this case initially he had features of left heart failure then eventually he developed pedal Edema
[5/30, 10:08] Post Residency PG1: Elaborate
[5/30, 10:10] MBBS 2016 UG Student 22: In this case of mitral stenosis pt initially presented with Dyspnea which Is symptom of lt heart failure then later he developed pedal edema (feature of rt heart failure)
If mitral stenosis is due to rt heat failure initially then the pt should present with pedal edema first???
[5/30, 10:11] Post Residency PG1: Dyspnoea is a symptom of failure of which part of the left heart?
[5/30, 10:12] Post Residency PG1: Left ventricle or left atrium? Particularly in mitral stenosis?
[5/30, 10:12] MBBS 2016 UG Student 22: Left atrium
[5/30, 10:16] Post Residency PG1: 👍👏👏Yes in pure mitral stenosis there is no left ventricular failure. Only left atrial failure due to left atrial outflow obstruction.
How does it lead to different grades of dyspnoea?
[5/30, 10:19] MBBS 2016 UG Student 13: Yes sir. We should consider that as well
[5/30, 10:20] Post Residency PG1: That would mean she has left ventricular failure and not pure mitral stenosis?
[5/30, 10:26] MBBS 2016 UG Student 20: Sir what is the reason for cardiomegaly in this case?
[5/30, 10:28] MBBS 2016 UG Student 13: If we consider the displacement of the apex, then yes sir.
[5/30, 10:28] MBBS 2016 UG Student 17: In mitral stenosis there is reduced ejection fraction with overload on left ventricle ... pulmonary congestion... Right ventricular hypertrophy and right heart failure... This is accompanied with tachycardia as a result to compensate the pathology which further deteriotes the condition of the patient decreasing the diastolic filling time.
[5/30, 10:31] MBBS 2016 UG Student 17: Hepatojugular reflex is an indicator of severe heart failure. Disorientation , fatigue and fluid retention may be the the symptom we need to see if the disease is severe.
[5/30, 10:32] MBBS 2016 UG Student 11: https://www.medicalnewstoday.com/articles/321034
[5/30, 10:35] MBBS 2016 UG Student 17: Left atrium*
[5/30, 11:07] Kims Surigi Mounika: Positive Hepatojugular reflex is an indicator of complete heart failure or right heart failure?
[5/30, 11:11] MBBS 2016 UG Student 5: it could be a marker of both elevated left-sided and right-sided filling pressures.
Hence, hepatojugular reflux should not be considered diagnostic of any particular condition, but an indication that the right ventricle cannot accommodate an increased venous return
[5/30, 11:12] MBBS 2016 UG Student 5: Constrictive pericarditis, right ventricular failure (commonly due to infarction), and restrictive cardiomyopathy are conditions that frequently produce a positive hepatojugular reflux
[5/30, 11:12] MBBS 2016 UG Student 17: It is an indication of heart failure of all the etiologies. It is not specific..to one..
[5/30, 11:12] MBBS 2016 UG Student 5: *Left ventricular failure also produces this sign, but usually when the PCWP is more than 15 mmHg.
***Cardiac tamponade does not lead to a positive hepatojugular reflux.
[5/30, 11:17] Kims Surigi Mounika: Okay
[5/30, 11:50] +91 93965 63779: Isn't it because of ventricular remodeling??
[5/30, 11:55] MBBS 2016 UG Student 16: Sir In the case of severe mitral stenosis, there is increase in the pulmonary venous pressure which transmits as a back pressure to the pulmonary arteries which leads to edema. This is the cause for Dyspnoea
In this case, I don't think this is the question that begets maximum attention. Ideally once the problem representation is put out, a list of problems triaged according to those requiring maximum attention should be put forth. My 2 cents. She has quite a lot of problems that require immediate attention than her bilirubin levels. Also her peridcardial effusion seems to have been underestimated. A total of the size of effusion in anterior, posterior and lateral areas may well be above 2cm which makes it highly significant.