Dr.

Chinmoy Saha
M.D. (Cardiology)
Phase B Resident
 Name-Rubel
 Age-40 yrs
 Sex-Male
 Occupation-Electrician
 Marital Status-Married
 Religion-Islam
 Address-Mughda,Dhaka
 Date of admission-29/4/2017
 Date of Examination-3/5/2017
 Shortness of breath for 2 months.
 Easy fatigability for the same duration.
 According to the statement of the patient,he
was reasonably well 2 months back.Then he
developed shortness of breath,more on
exertion,which is gradually increasing in
nature.Initially,the patient felt breathlessness
on moderate to severe exertion,but for the last
few weeks it has become so severe that he felt
breathlessness even on mild exertion.But he
has no history of breathlessness on lying flat
with no diurnal variation.
 He also complains easy fatigability after
exertion for the same duration which is
progressively worsening.
 On query,he mentioned about occasional cough
for last 4 months which was productive,with no
seasonal variation and not exacerbated after
posture change.He noticed streak of blood mixed
with sputum on three or four occasions.For this
reason,he consulted with a physician and he was
extensively investigated for tuberculosis.But
investigations were negative.For further
evaluation he was referred to a cardiologist and
he was diagnosed as a case of valvular heart
disease.With these complaints he got admitted in
DMCH on 28/4/17 for further management.
Throughout the course of his illness,he had
no history of weightloss,fever,palpitation,chest
pain, leg swelling,hoarseness of voice or
difficulty in swallowing.
 No history of childhood fever with joint pain.
He comes from a low socio economic family.
He lives in paka house and use sanitary latrine.
 He has three sisters.
 Parents are alive.
 No such illness runs in his family.
 He could not mention properly.
 Tab.Phenoxymethyl penicillin 250mg
1+0+1
 Tab.metoprolol 25 mg
½+0+½
 Appearance: ill looking
 Body built: average
 Co-operation: cooperative
 Decubitus: On choice
 Anaemia: absent
 Jaundice: absent
 Cyanosis: absent
 Koilonychia: absent
 Leukonychia: absent
 Clubbing: absent
 Dehydration: absent
 Edema: absent
 Pulse:72 beats/min,regular,low volume
 BP: 100/70 mm of Hg
 Respiratory rate:14/min
 Temp: 99 F
 JVP: Not raised
 Lymphnode: no lymphadenopathy
 Thyroid gland: no thyromegaly
 Inspection: A visible impulse on the left 5th
intercostal space
 No scar mark or bony deformity

 Palpation: Apex beat is felt in left 5th

intercostal area just medial to the
midclavicular line,tapping in nature
 Right parasternal heave is present
 Palapable P2 is present
 1st heard sound is loud in mitral area normal
in other area
 Pulmonary component of 2nd heart sound is
also loud in pulmonary area
 There is low pitched,localised,rough,rumbling
murmur best heard on mitral area,in left
lateral position with the bell of the
stethoscope,breath hold after expiration with
presystolic accentuation.
 Opening snap is also present.
 Base of Lungs: Clear
 Reveals no abnormality
 Mitral stenosis with pulmonary HTN
 Tricuspid stenosis
 CBC:
Hb:14 gm/dl
TWBC :8000/mm3
N:62 %
Esr:20 mm
 S.Creatinine:1.3 mg/dl
 S.Electrolyte: Na :143 mmol/l
K: 4.63 mmol/l
 Chronic rheumatic heart disease with
moderate mitral stenosis with pulmonary
hypertension
 Medical Therapy
 Intervention -PMV
 Surgery
1.CMC
2.OMC
3.Mitral Valve replacement
 1.Patient without symptoms,who has mild MS
need no specific treatment ,only prevention
of rheumatic fever.
 2.Only mild symptoms of exertional dyspnea
can be treated with diuretics.
 3.For atrial fibrillation,rate control measure or
cardioversion.
 4.Anticoagulant may be used.
 1.Score Higher than 11: should not undergo

valvuloplasty

 2.Score of 9-11: gray zone,suboptimal result

 3.Score less than 8 : optimal result

 TAB.Phenoxymethyl Penicillin 250mg
1+0+1
 Tab.Frusemide+spirolactone 20/50
1+0+0
 Tab.Levofloxacin 500mg
0+0+1
Tab.Rabeprazole 20mg
1+0+1
Thank You