Mitral Stenosis (Case Presentation)

Mitral Stenosis (Case Presentation)

1. Case Presentation By : Azhan Jamal Iqra Nurie Sabeen Javed Syed Haris Mustafa Muhammad Hasan CPC 11 th August 2017

2. BIODATA NAME: Tariq AGE: 18 years Sex: Male Address: Khairpur (Zakria Goth) Mode of Admission: Emergency Date of Admission: 28.7.17 Time of Admission: 1:00pm Bed No.: 04 Ward: MWU1

3. PRESENTING COMPLAIN : Fever for 3 months Cough for 3 months SOB for 3 months HISTORY OF PRESENTING COMPLAIN: According to my patient he was in a usual state of health 10 years back when he developed fever which was sudden in onset,continuous in nature, high grade fever, not documented and was not associated with rigors and chills or night sweats. For this complain my patient visited a local practioner who prescribed him with a medication that is CALPOL (Paracetamol) by which the fever subsided. Two years after that my patient again had the same complain of fever which was sudden in onset,high grade and continuous in nature, he again went to a local practioner and was pescribed with the same medication Then after 3 years when he was 13 years old he went to a general practioner with a complain of a number of swellings in the neck (at the post auricular region) and was suspected to have Lymphadenopathy with Red Rashes, which was resolved after 8 days

4. Now from 3 months he is suffering from Fever which was sudden in onset, Intermittent in nature, high grade and is not associated with Rigors and Chills or night sweats. He Also complains for SOB from last 3 months which have a duration of 10 minutes and is aggrevated on taking 40 to 50 steps or climbing up to 10 to 15 stairs.It also occurs at night with sudden awakening and is also associated with cough,Palpatation and Sweats Cough was non productive,sudden in onset,Mild in severity and is Intermittent in nature.Duration is upto 5-7 minutes per episode,Occurs more at night with no history of hemoptysis

5. SYSTEMIC REVIEW: CARDIOVASCULAR SYSTEM: SOB ----------- + ve Chest Pain ------- + ve Palpatations -------- + ve Edema ------------- - ve RESPIRATORY SYSTEM: Cough -------- + ve Sputum ------- - ve Hemoptysis -------- - ve Wheezing --------- - ve

6. GASTROINTESTINAL TRACT: Nausea ------ - ve Vommiting -------- - ve Diarrhea ----------- - ve URINARY SYSTEM Dysuria ------- - ve Burning Micturation ---- ve Polyuria ----------- - ve CENTRAL NERVOUS SYSTEM: Weakness -------- + ve Vertigo ---------- - ve Headache ------- - ve Fits -------- - ve

7. PAST MEDICAL HISTORY: My patient had a history of visiting general practioners and taking medications for fever from last 10 years PAST SURGICAL HISTORY: No history of any previous surgery DRUG HISTORY: Calpol (Paracetamol) PERSONAL HISTORY: Sleep is normal, Appetite is normal,there is no history of any addiction to tobacco,Pan,Niswar etc. Bowel habbits are all normal

8. FAMILY HISTORY: Total number of family member is 5 Patient,s Mother have HTN There is no history of TB, DM in the family SOCIO-ECONOMIC HISTORY: My patient lives in a Cemented house with 3 rooms. Drinks tap water. Proper sanitization and has a pet goat in the house

9. EXAMINATION

10. EXAMINATION: GENERAL PHYSICAL EXAMINATION: My patient is an ill looking young boy lying comfortably on bed. He is conscious, well organised and well oriented with time,place and person. He is lean and of normal height with no catheterisation or canulisation . VITALS: BLOOD PRESSURE: 100/70mmHg PULSE RATE: 78 beats/min RESPIRATORY RATE: 21 breaths/min TEMPERATURE: 98.6F

11. SUBVITALS: PALLOR: Present JAUNDICE: Absent CLUBBING: Absent KOILONYCHIA: Absent LEUKONYCHIA: Absent CYANOSIS: Absent SPLINTER HEMORRHAGES: Absent OSLER’S NODES: Absent HERBERDEN’S NODES: Absent BOUCHARD’S NODES: Absent HAND DEFORMITY: Absent HAND SIZE AND SHAPE: Normal PALMAR ERYTHEMA: Absent

12. Dupuytren’s contracture: Absent Janeway lesion : Absent Periorbital edema: Absent Proptosis : Absent Pedal Edema: Absent Skin rash: Absent Parotid glands: Not enlarged Thyroid: Normal size , non tender , no bruit . JVP: not raised Lymph nodes: Not palpable . Dehydration: Absent

13. SYSTEMIC EXAMINATION: CARDIOVASCULAR EXAMINATION : PULSE : RATE : 78 Beats/min RHYTHM: Normal VOLUME: Normal No radiofemoral delay. Peripheral pulses palpable. B) BLOOD PRESSURE: 100/70 mmHg C) JVP is not raised. D) EXAMINATION OF PRECORDIUM: INSPECTION : Chest is pigeon shaped. There is a buldging on midsternum . There is a visible apex beat. No other pulsations visible. No scar marks or pigmentation. (video on next slide)

14. PALPATION : 1.Apex beat is palpable in 6 th intercostal space at the midclavicular line. It is heaving in character. 2.Left parasternal heave palpable. 3. Mid diastolic thrill palpable at apex. 4.P2 is palpable. 5.No palpable pericardial rub. AUSCULTATION: 1) S1+S2= Audible 2)S1 is louder than S2. 3)P2 is loud. 4)Mid diastolic murmer is heard in mitral area, It is of grade IV, harsh,localised,increased on expiration and decreased on inspiration. The murmur becomes loud in late diastole. 5) Opening snap heard.

15. RESPIRATORY EXAMINATION: INSPECTION: On inspection, respiratory rate is 21 breaths/min. Type of respiration is abdominothoracic . Shape of the chest is pigeon shaped. There is visible harrison sulcus . Apex beat is visible on mitral area. Chest is moving symmetrically on both sides. There are no visible scar marks, stria or pigmentation, No flattening or retractions. PALPATION: No tenderness or crepitus . Trachea is centrally placed. Apex beat palpable in 6 th intercostal space at midclavicular line. Chest is moving symmetrically on both sides. Chest expansion is normal. Vocal fermitus is normal.

16. PERCUSSION: Percussion note is resonant and equal on both sides. Upper border of liver is in right 6 th intercostal space. AUSCULTATION: B reath sounds are vesicular and of normal intensity. No added sounds heard. Vocal resonance is normal and equal on both sides.

17. ABDOMINAL EXAMINATION : INSPECTION: Shape of the abdomen is sunken. Abdomen is moving with respiration. No visible peristalsis. Umblicus is centrally placed and inverted. No visible pulsations,scar mark,stria or prominent veins seen. Hernial orifices are intact. PALPATION: SUPERFICIAL PALPATION: On superficial palpation there is no rigidity and tenderness. DEEP PALPATION: On deep palpation,there is no tenderness or rebound tenderness and no mass palpable. On palpation of the visceras , Liver span is 10cm (No hepatomegaly ), spleen is not palpable, Kidney is not palpable bimanually, no fluid thrill, murphy’s sign is negative.

18. PERCUSSION: Shifting dullness absent. AUSCULATION: Bowel sounds audible and of normal intensity. No bruit or friction sound audible.

19. CENTRAL NERVOUS SYSTEM EXAMINATION : HIGHER MENTAL FUNCTION: Patient is alert and co operative. He is well oriented in time,place and person. Behaviour is normal.There are no delusions or hallucinations. GCS is 15/15. Memory is good and general intelligence is normal. 2) SPEECH : Normal 3) All cranial nerves are intact. 4)MOTOR SYSTEM : Bulk : Normal in both upper and lower limbs. TONE : Normal in both upper and lower limbs. POWER : Normal in both upper and lower limbs. REFLEXES : NORMAL. NO INVOLUNTARY MOVEMENTS. GAIT: Normal 6) SENSORY SYSTEM : Touch,pain,temperature,position,passive movements and vibration are intact .

20. 7)SIGNS OF MENINGEAL IRRITATION: NOT PRESENT (Neck rigidity,kernig’s sign and brudzinski sign negative) 8) CEREBELLUM : Nystagmus is absent. Speech is normal. No tremours . Co ordination is intact. Repetitive movements are normal.Gait is normal. 9) NO SIGN OF LATENT TETANY (TROUSSEAU’S AND CHOVOSTEK’S SIGN NEGATIVE)

21. Differential Diagnosis Mitral Stenosis due to Rheumatic Heart Disease Atrial Septal Defect Systemic Lupus Erythematosus Infective Endocarditis

22. INVESTIGATIONS CBC ESR ASOT C-XRAY ECG ECHO

23. MANAGEMENT

24. How this patient was managed in Fatima hospital? Augmentin 1.2 gms IV which was followed by B.D orally. Panadol x 2 B.D Nub with Atrovent (Ipratropium) Carveda (B-blocker) 6.25 mg B.D Lasik( Furosemide) 20mg O.D After we observed him for few days, we refered him to NICVD for his further treatment.

25. MANAGEMENT: Patient with minor symptoms should be treated medically,but the definitive treatment is surgical. MEDICAL MANAGEMENT : Sodium restriction and diuretics for pulmonary edema and congestion. In Atrial fibrillation: B-blocker, calcium channel blockers or digoxin ( 0.125-0.25 mg/day) for rate control. Once Atrial fibrillation occurs, the patient should receive warfarin (anticoagulant) therapy. Since 20-30% of these patients will have systemic embolization if untreated. 4. Antibiotic prophylaxis against infective endocarditis is no longer routinely recommended.

26. BALLOON VALVULOPLASTY: This will be performed if the following criteria is fulfilled. Significant symptoms No mitral regurgitation Mobile non-calcified valves Left atrium free of thrombus. PROCEDURE: In this procedure catheter is introduced into the right atrium via femoral vein, interatrial septum is then punctured and catheter advanced into the left atrium and across the mitral valve balloon is passed over the catheter across the valve and then inflated briefly to split the valve commissure.

27. SURGICAL MANAGEMENT : Following surgical options are available: CLOSED VALVOTOMY: INDICATIONS: Mobile, non-calcified and non regurgitant mitral valve. 2)OPEN VALVOTOMY: INDICATIONS: Calcified valve or with left atrial thrombus. 3) VALVE REPLACEMENT: INDICATIONS: 1) Mitral stenosis with mitral regurgitation. 2) Immobile calcified valve. 3)Left atrial thrombus despite anticoagulation.

28. MITRAL STENOSIS Subtitle

29. A clinicopathological condition characterized by narrowing of mitral valve resulting in left atrial hypertrophy and dilation. CAUSES: Rheumatic Heart Disease (most common cause) Congenital Carcinoid Syndrome Bacterial vegenation Mitral annular calcification SLE

30. Class Valve area(cm2) Symptoms Minimal >2.5 None Mild/Moderate <2.5 - >1.-0 Dyspnea ,Orthopnea,PND,Pul Edema Severe <1.0 Resting Dyspnea, disabled/bed chair

31. Symptoms Dyspnea Palpitation Fatigue Dysphagia Hemoptysis Embolic event Signs Palpation of S1 (Pathognomonic) Dystolic Thrill/Mid- dystolic murmur (Left lat. decubitus position) Apex beat: Localized and tapping Heart Sounds: S1 loud Opening snap Right parasternal heave; Pulmonary Hypertension Malar f a cies (Blue dusky appearance on cheeks) Rising JVP Graham-Steel murmur ( Pul . HTN and Severe MS)

32. KEY DIAGNOSIS Exertional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Fatigue Opening snap Loud S1 Mid- Dystolic Murmur Pulmonary HTN ECG : - Atrial Fib. - Bifid P wave CXR : - Straightening of left heart border (left atrial enlargement) ECHO : - Thickened mitral valve - Reduced Orifice area