WHITE ARMY CLINICAL CASE

PRESENTATION
Aparna S N
4th Year MBBS
JNMC Belagavi
Arpana

Clinical case presentation

Name: Mrs XYZ
Age:39 years
Occupation: Homemaker
Address: Maruti galli, Belgaum
Socio economic status: Class IV (Lower Middle class) Modified BGP
Religion: Hindu
Education:8th standard
DOA: 4-03-20
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CHIEF COMPLAINTS

• Breathlessness since 2 months

• Chest pain since 1month
• Palpitations since 1 month

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 2months ago when she started developing
breathlessness which was insidious in onset and progressive in nature. It was
initially only on climbing stairs(2 flights of stairs) and now has progressed to
an extent that she feels breathless even on doing her routine work like
washing clothes,vessels i.e from Grade 2 to Grade 3 according to NYHA
Grading of Breathlessness.
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Patient also gives history of breathlessness at night because of which

she had to wake up frequently(2-3 times) and go to the open window
i.e history of PND attack since 20days.
Patient also complains of chest pain since 1month which was insidious
in onset and progressive in nature. Pain is located on the precordium
near the midline( retrosternal area) and is of constricting type, non
radiating in nature. It aggravates on exertion and relieves on rest.
Patient also complains of palpitations since 1month which was
insidious in onset and progressive in nature. It aggravates on exertion
and subsides on rest. It is regular in character.
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no h/o breathlessness in supine position-orthopnea

no h/o breathlessness in sitting position-platypnoea
no h/o swelling of feet
no h/o cough with expectoration
no h/o wheeze
no h/o recent fever
no h/o hemoptysis
no h/o hoarseness of voice
no h/o dysphagia
no h/o syncope
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Cardinal Symptoms
• Cardiac Chest pain
• Ischemic / Pericardial pain / Pain of MVP
• Breathlessness
• Exertional / PND / Orthopnea
• Palpitation
• Syncope / Exertional graying of vision
• Edema
• Easy fatiguability
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NYHA functional assessment

(In a patient with Heart disease)
• Class I-
• No limitation of activity
• Class II-
• slight limitation
• Class III-
• marked limitation
• Class IV-
• symptomatic at rest
CR HISTORY OF PRESENTING ILLNESS
Patient presented with aggravation of her longstanding exertional
breathlessness without wheeze----Yrs.
She does not remember exact timing / date of onset (insidious) of her
first DOE. To begin with it was not limiting her routine activity , but
used to appear only on strenuous / unaccustomed activity( ? effort tolerance
level less than that of her peers.) It gradually progressed over several years.

Her dyspnoea gradually builds up prapotionate with the level of activity

and relieves on talking rest. It persisted same way for quite long time (--
months / years).
She had sudden aggravation of dyspnoea since last 2 months, to the
current stage of dyspnoea limiting her routine household activity. ( There
was no h/o persistent / sudden aggravation of dyspnoea in the course of illness,)

No history s/o PND / Orthopnea in the course...,

No H/o Cough / expectoration/ hemoptysis..
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She gives h/o of intermittent exertional palpitations ( perception of fast /

forceful heart beats)since many months, which used to appear after onset
of DOE. Her palpitation also increases proportionate to level activity
and relives gradually on resting for sometime.
It is regular in character.

No h/o of palpitation at rest / Sudden onset - offset / irregular

palpitation / syncope in the course of her illness.

No h/o swelling of feet/anorexia / wt loss/ persistant fever/ hematuria

/ hoarseness of voice / dysphagia
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Palpitation
undue uncomfortable awareness of heart beating

• Ask patient to tap palpitations on chest

• Speed of onset or offset
• Slow or fast
• Regular or irregular
• Duration
• Severity
• ? Asso chest pain, dyspnoea, syncope
• Relieving manoeuvres
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Palpitation - Mechanism
• Abnormal rate
• Tachycardia- Fever/ exercize/ Anxiety/SVT/VT/ salbutamol/ Thyrotoxicasis/ Anemia..
• Bradycardia- CHB

• Abnormal rhythm
• VPC, AF, MAT, A Flutter…

• Abnormal force of contraction

• Pressure overload
• AS, HTN, HOCM ; MS ( LA pr)
• Volume overload
• AR, MR, VSD
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Past history
h/o frequent episodes of fever, sore throat and joint pains in
childhood which relieved on medication prescribed by local doctor.
Similar episode 9 years back for which she was admitted in hospital and
then started on Benzyl penicillin injections every month.
Two uneventful pregnancies(NVD)
No h/o diabetes mellitus, hypertension,Blood transfusion,TB

Family history
No history of similar complaints among family members.
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Past Medical History

• ?Rheumatic fever
• Fever, fleeting polyarthritis, edema..
• Monthly LA Penicillin inj.

• ?Previous infective endocarditis

• Prolonged fever, hematuria, daily 5-6 injections for long hospitalisation
period

• ?Previous CCF
• Edema, orthopnea, fatigue, drugs (5/7 days, Diuretics..)

• ?Previous cardiac investigations & interventions

• ?Previous myocardial infarction
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Medications
• Anti-anginal agents
• Use of sublingual nitrate spray
• Diuretics
• Digoxin
• Antihypertensive agents
• Anti-arrhythmics
• Statins
• Platelet inhibitors, e.g., Aspirin
• Anticoagulants, e.g., Warfarin

• Allergies ??
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Past history
She gives h/o Fever, sore throat and multiple joint pains in childhood
which relieved with medications.
Similar episode of Fever, sore throat and multiple joint pains recurreed
9 years ago, for which she was admitted & evaluated in hospital and
then started on monthly painful injections / Benzyl penicillin injections
every month.
Two uneventful pregnancies(NVD) ; 1st was –yrs ago; 2nd—yrs ago.
No h/o diabetes mellitus, hypertension, Blood transfusion, TB

Family history
No history of RHD / IHD/ HT/DM / similar complaints among family
members.
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Menstrual history
Menarche:- 14 years
Menstrual cycle:- 3-4 days/month, normal and regular

Personal history
Diet: vegetarian
Appetite: normal
Sleep: disturbed
Bowel and Bladder: normal and regular
Habits: no smoking, alcohol consumption, tobacco chewing
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Summary
This 39year old lady comes with complaints of NYHA grade 3
breathlessness since 2months. She also complains of
constricting type of retrosternal chest pain and palpitations
which are regular since 1month and paroxysmal nocturnal
dyspnea since 20days. She has a past history suggestive of
rheumatic fever, with repeated remissions.
So my provisional diagnosis on the basis of history is of cardiac
disease with symptoms of pressure overload state due to
valvular pathology and rheumatic in origin i.e Rheumatic
Heart Disease with mostly mitral valve involvement.
Arpana
Differential diagnosis

1. Left atrial myxoma

2. Cortriatum
3. Ball valve thrombus of left atrium
4. Atrial Septal defect
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Summary- history Clues to the possibilities
• Exertional dyspnoea ( PND, Orthopnea) = Lt sided / Pressure overload
= MS, AS , LVF, / IHD- Angina equivalence..
• Edema- RVF/ CCF
• Palpitation= Volume overload(MR, AR, VSD)/ Arrhythmia= AF, SVT …
• Exertional Syncope= Fixed CO status= AS, HOCM, PS,PAH, CHB
• Hemoptysis- MS, pulmonary edema

• Risk stratification ( atherosclerosis)

• Anginal chest pain - Myocardial ischemia

• Cyanotic episodes - TOF, Eisenmangers

• Squatting-TOF
• Intermittent Claudication- PVOD
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Summary
This 39year old lady with history s/o 2 episodes of Rh fever, on regular
Bezathine Pen prophylaxis---yrs?, continuing till date presented with
gradually progressive exertional breathlessness of ---/ yrs duration
/??months!. Without wheeze/ PND/orthopnea. She also has recent onset of
excertional, regular palpitation with gradual onset & offset . However there
is no h/o Exertional syncope / chest pain, Leg edema, Fever/ hematuria/
cough / expectoration.

So my provisional diagnosis on the basis of history is of Left sided cardiac

disease suggestive of pressure overload state due to mitral valvular
pathology – most likely MS of Rheumatic origin, without any complications
like PH/ CHF/ IE/ AF by history.
However I would like to consider possibility of Rh reactivation / Infections/
pregnency/ new onset Anemia/ Dysthyroidism/ SBE/ AF /CHF for the recent
aggravation of her symptoms.
• Other possibilities are:
•IHD – unlikely ( Gender/ Age/ other risk factors-ve)
•Pulmonary disease – ILD / Emphysema / Pleral effusion ..??? ..(unlikely due to....)
•Anemia / Thyrotoxicosis..(unlikely due to....)
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PHYSICAL EXAMINATION
General Survey
Patient is a 39year old lady, sitting comfortably on bed and is moderately
built and nourished. She is conscious, cooperative and well oriented to time,
place and person.
Wt=47kg
height= 156cm
BMI=19.31kg/m2
Vitals
PR=72bpm
BP=110/78 mm Hg on right upperlimb in sitting position
RR=16cpm
Temp=99.8 degree F
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No Pallor
No Icterus
No clubbing
No cyanosis
No Lymphadenopathy
Mild pitting pedal edema present
No other features like Oslers nodes, Janeway lesions suggestive of
Infective Endocarditis
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Systemic Examination
Peripheral CVS
Pulse: Rate-72bpm
Rhythm-Regular
Volume-Low
Character-Normal
Condition of vessel wall-normal
No radio-radial or radio-femoral delay
Signs of CCF
1)Pedal edema present 3)No tender hepatomegaly
2)No raised JVP 4)No Abdominojugular reflex
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GPE
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Arterial pulse
• Radial A - Position.
• Rate
• Rhythm
• Volume
• Character
• Wall thickness
• R-F delay
• A-P deficit
• ?All peripheral pulses bilaterally
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Position – Radial Pulse

• Elbow jt & wrist semi flexed

• Forearm semi pronated
• Palm rests across upper part of the abdomen
• Good relaxation
• Feel the pulse medial to radial styloid with 3
fingers
• Count pulse for 1 min.
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Pulse Rate
Normal = 60- 100/ min
• Tachycardia (>100/min )
• Exercise,
• Bradycardia (< 60/min) • Anxiety,
• Athlets, • Pregnancy,
• Betablocker, • Fever,
• Digitalis, • Anemia
• Heart block, • Salbutamol,
• SSS, • Atropine…
• Myxoedema, • CCF,
• MI, • Carditis,
• Raised ICP • Thyrotoxicosis,
• AF,
• SVT,
• Shock..
• Raising pulse rate – increasing vol loss
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• Rhythm = beat to beat regularity of pulse.

• ? Regular = beat to beat interval is constant

• ? Irregular = varying interval between 2 beats

• ? Regularly irregular
• MAT, Atrial flutter with blocks, Bigeminy, Trigeminy

• ? Irregularly irregular
• Atrial fibrillation, Multiple vpc

• ? Pulse deficit
• HR - PR
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Volume

• Pulse pressure

• Normal ( PP 30-60mmHg)

• High- bounding pulse (PP>60mmHg)

• Anemia, Fever, MR, VSD, Beriberi..

• Low- thready pulse (PP<30mmHg)

• CCF, Shock, AS, MS..
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Character

• Pulsus alternans
• (left ventricular failure)

• Pulsus bisferiens-
• (AS+ AR, sever AR, HOCM)

• Pulsus parvus - low volume normal character pulse

• ( Shock, MS, PS, AS, PAH, CCF, )
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Character

• Pulsus parvus et tardus

• (Sever AS)

• Pulsus paradoxus
• (Acute sever asthma, Pericardial tamponade)

• Collapsing pulse
• AR, PDA,AV fistula, Beriberi, Pagets disease
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? All peripheral pulses palpable
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Jugular Vein Assessment
• ?Visible
• if so How much &
• ? Wave pattern

• Jugular venous distension (IJV)

• Patient supine with head of bed at ~45 degrees
• Observe for venous pulsations in the neck (tangential light)
• Identify highest point of pulsation
• Using horizontal line from this point, measure vertically to sternal
angle...should be less than 3-4 cm in healthy adult

• Hepato-jugular reflux
• Patient supine with head of bed @ 30-60 degrees
• Gently press liver / upper abd while watching jugular vein
• May see wave level rise with right heart congestion
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JVP
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Wave patterns
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Causes of raised JVP

• CCF
• Pericardial effusion, tamponade
• TS, TR
• PS, PAH
• RV infarction
• ASD
• Fluid overload
• ARF, CRF, AGN, IV fluids

• SVC obstruction – non pulsatile

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• Large a wave • Steep x, y descent

• TS • Constrictive pericarditis
• Ps • Cardiac tamponade
• P HT
• Absent a- AF • Large v wave
• TR
• Cannon wave
• CHB • Kussumals sign (↑JVP in inspiration)
• VT • Constrictive pericarditis
• Junctional rhythm • Cardiac tamponade
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? RAISED JVP
• HEART FAILURE – ELEVATION, SUSTAINED HJR

• PERICARDIAL EFFUSION- ELEVATED, PROMINENT Y DESCENT

• CONSTRICTIVE PERICARDITIS-ELEVATED, KUSSMAULS= PARADOXICAL RISE ON INSPIRATION

• AF NO a WAVES

• TRICUSPID STENOSIS- GIANT a WAVES

• TRICUSPID REGURG- GIANT v WAVES

• COMPLETE HEART BLOCK- CANNON WAVES

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PHYSICAL EXAMINATION
Patient is a 39year old lady, sitting comfortably on bed and is moderately built
and ? Poorly nourished. She is conscious, cooperative and well oriented to time,
place and person.
Wt=47kg, height= 156cm ; BMI=19.31kg/m2
Vitals: Pulse is 72bpm, Regular in Rhythm, Low volume, Normal Character &
vessel wall. There is no radio-radial or radio-femoral delay.
BP=110/78 mm Hg on right upperlimb in sitting position with PP of 30 mmHg
RR=16cpm; Temp=99.8 degree F
No Pallor/Cyanosis/ clubbing /Lymphadenopathy/ Icterus
Mild B/L, symmetric , non-tender pitting pedal edema present ( till extent)...
JVP is not elevated / No Abdomino- jugular reflex ( HJR) / Tender liver to sug CCF
No signs of IE/ SBE like Oslers nodes, Janeway lesions, Splincter hge/ Petriche
Central CVS
1) Inspection
No Thoracic wall abnormalities
Precordial bulge present
Apical impulse not seen
Pulsations other than apical impulse:
No Supraclavicular pulsation
Parasternal pulsation present
No Suprasternal pulsations
No Epigastric pulsations

Trachea / Scars/ Sinuses / Venous engorgement ....????

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Precordium - Inspection
▪ Scars
 Median sternotomy
 CABG
 Valve replacement
 Lateral thoracotomy
 Infraclavicular (pacemaker)
▪ Pectus excavatum
▪ Apex beat
▪ Left parasternal heave
▪ Epigatric impulse
▪ Suprasternal pulsations
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2) Palpation
No tenderness
Apical impulse location: Left 5th ICS lateral to mid clavicular line
character: Tapping character
Left parasternal pulsations present
Left parasternal heave(grade 2) present
Palpable P2 present
Diastolic thrill felt in mitral area
3) Percussion
Dull note on left 2nd Inter-costal space

Apex & Rt heart border?? / Contra indications??

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Precordium - Palpation
▪ Apex beat
 Location
 Character
 Normal
 Thrusting / forcible
 Heaving
 Double
 Tapping
 Paradoxical
▪ Epigatric impulse ? type
▪ Left parasternal heave
▪ Thrills (palpable murmurs)
 Systolic
 Diastolic

▪ Palpable P2 (pulmonary hypertension)

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4) Auscultation
Loud first heart sound heard in mitral area
Low pitched, rumbling mid diastolic murmur best heard in left lateral
position with bell of stethoscope.
Opening snap is heard in left lower parasternal area with the diaphragm
of the stethoscope.
No other added sounds like S3,S4,tumor plop
Tricuspid area
Normal S1 and S2 heard
Pulmonary area
Normal S1 and loud P2 heard
Aortic area
Normal S1 and S2 heard
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Precordium – Auscultation - Heart Sounds

▪ Bell – low pitched sounds

▪ Diaphragm – high pitched
sounds
▪ Mitral → Tricuspid →
Pulmonary → Aortic areas
▪ S1 (first heart sound)
▪ S2 – Splitting (A2, P2)
▪ Additional sounds
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Abnormalities of Heart Sounds

• Loud S1 • S3 (third heart sound)

• Soft S1 • S4 (fourth heart sound)
• Summation gallop
• Loud A2
• Loud P2 • Opening snap

• Increased splitting of S2 • Systolic ejection click

• Fixed splitting of S2 • Mid-systolic click
• Reversed splitting of S2 • Tumour plop
• Pericardial knock
• Metallic click
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Precordium – Auscultation; Murmurs

• Timing of murmur
• Systolic
• Pitch
• Diastolic
• Continuous • Radiation
• Dynamic manoeuvres
• Site of maximal intensity @ origin • Respiration
valve • Left-sided  on exp.
• Right-sided  on insp.

• Loudness • Valsalva
• Grades I-VI • Squatting
• Thrill
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Heart Murmurs
• Systolic
• Pansystolic
• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
• Ejection systolic
• Aortic stenosis
• Pulmonary stenosis
• HOCM
• Atrial septal defect
• Late systolic
• Mitral valve prolapse
• Diastolic
• Early diastolic
• Aortic regurgitation
• Pulmonary regurgitation
• Mid-diastolic
• Mitral stenosis
• Tricuspid stenosis
• Carey combs
• Austin flints
• Atrial myxoma
• Continuous
• Patent ductus arteriosus
• Arteriovenous fistula
• Pericardial friction rub
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Per abdomen examination
Non-tender, no organomegaly
Respiratory system
Normal vesicular breath sounds heard
CNS Examination
Higher mental functions are intact

Provisional Diagnosis
Rheumatic Heart disease with Mitral stenosis associated with
pulmonary hypertension in sinus rhythm with no evidence of
congestive cardiac failure at present.
( No E/O endocarditis)
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Provisional Diagnosis
Young lady with past 2 RF, on Rh prophylaxis, presenting with DOE &
Palpitation, O/e has Tapping regular apical impulse at normal position,
Loud S1, OS & MDM with PSA suggestive of:

Rheumatic - Mitral Stenosis(Mild/ mod/ severe), in sinus rhythm. It is

complicated by pulmonary hypertension ( LPH, Loud P2) but no
evidence of CHF / endocarditis.
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Mitral Stenosis
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Mitral valve
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Mitral stenosis (MS)

• An obstruction to blood flow from the left atrium to left ventricle at mitral
valve .

• Isolated MS or coexists with MR.

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Grades of Mitral Stenosis

• Valve Area:
• >1.5-2.5 cm2 ➔ Mild →( Asymptomatic!)
• 1.0-1.5 cm2 ➔ Moderate →( Mild Class II/ III )
• <1.0 cm2 ➔ Severe →( Class IV / PND/ Orthopnea)
• < 0.8 cm2 → Critical →( Class IV / PND/ Orthopnea)
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Causes
• Rheumatic
• Congenital, Parachute…
• Prosthetic valve
• Carcinoid

–LA myxoma
–LA ball valve thrombus
–Cor triatrium
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Pathologic changes @ mitral valve apparatus

• Fusion of the leaflet commissures

• Thickening, fusion and shortening of the chordae ten (→ MR).

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MS: Pathophysiology
Right Heart Failure: LA Thrombi
Hepatic Congestion Atrial Fib
JVP Elevation LA Enlargement
RA Enlargement  Pulmonary HTN
Tricuspid Regurgitation Pulmonary Congestion
 LA Pressure
ms
RV Pressure Overload
RVH
RV Failure LV Filling
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symptoms
• DOE
• PND
• Orthopnea

• Fatigue
• Palpitation
• Hemoptysis..
• Recurrent bronchitis
• Systemic emboli..

• F/o ccf
• Hoarseness , Dysphagia
• f/o IE
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signs

• Tapping apex
• JVP….
• Loud S1
• OS
• MDM with PSA
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• First heart sound (S1) is LOUD

• Opening snap (OS) after A2
• Low pitch MDM / diastolic rumble at the apex
• Pre-systolic accentuation (only if in NSR)
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If PH complicating MS
• JVP ↑, a ↑
• LPH
• Pul A pulsation
• LOUD P2
• ESM & EDM
• PSM-TR
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If AF complicating MS
• Irregularly irregular pulse
• Pulse deficit >10
• Absence of a wave in JVP
• Apex & S1 variable intensity

• No S4
• No Pre systolic accentuation of MDM
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Sudden worsening in MS
▪ AF
▪ Exercize
▪ Infection / Fever
▪ Stress
▪ Pregnancy
▪IE
▪ Anesthesia
▪ IHD
▪ CCF
▪ Dysthyroid
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D/D
▪ Inflow obstruction
 LA myxoma, BV thrombus, HCM
▪ Diastolic murmur
 TS, AR, ASD
 Carry combs; Austin flints
▪ Diastolic sound resembling OS
 Constrictive pericarditis
 Restrictive myopathy
▪ Loud S1
 Tachycardia, MVP, hyperdynamic state;
 Thin Chest wall; Short PR
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CXR
• Straightening of LHB
• Shadow through shadow
• Lifting up of LMB- widened carina
• Mitral calcification
• Prominent upper lobe veins
• Esophageal indentation on Ba swallow (LAO)
• Pul hemosiderosis- calcific specs
• Kerley Blines
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ECG
• P mitrale
• AF
• RVH
• RAD
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echo
• Thick mitral leaflets
• Doming of aml
• Paradoxic pml motion
• Reduced ef slope
• Calcific mv
• Valve area
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Medical Rx
• Rheumatic prophylaxis
• IE prophylaxis

• Diuretics
• Digoxin
• Anticoagulants
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Interventions

• BMV

• CMV
• OMV

• MVR
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Complications
• AF
• PH
• Pulmonary edema
• Hemoptysis
• CCF
• IE
THANK YOU
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Management

Investigations
1.Blood investigations
Complete Blood count, ASO Titre
2.ECG
Wide notched P waves( P mitrale) s/o LA enlargement
3.Echocardiography
To look for chamber enlargement, LA thrombus, Valve pathology, Valve
area etc.
4.Chest X-ray
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Chest X ray possible findings
• PA View
1)Mitralisation of heart i.e straightening of left heart border.
This is due to:
1.Small Aortic knuckle due to low cardiac output
2.Convexity due to dilated pulmonary artery due to pulmonary
hypertension
3.Double contour of the right border of heart
(shadow within shadow)
2)Splaying of carina
3)Bedford sign
4)Walking man sign
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• Right anterior oblique view

RAO with Barium filled esophagus is done, in presence of enlarged
left atrium sickling of esophagus is seen since esophagus is pushed
backwards.

• Lateral view
Sternal contact sign(obliteration of the retrosternal space)
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TREATMENT
1. Medical treatment-
Rheumatic fever prophylaxis

Digoxin, diuretics, antibiotic prophylaxis

1. Surgical- Percutaneous mitral balloon valvuloplasty

Trans septal balloon mitral valvotomy
Closed mitral valvotomy
Open mitral valvotomy
Mitral Valve replacement
(mechanical or tissue valve prosthesis)
THANK YOU