PGDCC 2012 Interactive Clinical Case Session

CASE No.1:
45yrs female presented with increasing SOBE and lowgrade intermittent fever of 15 days duration. She was suffering from progressive SOBE since 16yrs of age. In the initial years she had few episodes of SOB in the late hours of night for which she had to get up from the sleep, and sit upright and cough out pink, frothy sputum for getting relief. She had one episode of hemoptysis at the age of 19yrs.Presently she was having SOB on routine activity. She also suffered from palpitation since 24yrs of age. At the age of 28yrs, she had one episode of sudden increase in palpitation followed by transient weakness of left upper limb which lasted for few hours. There was no residual weakness and no recurrence of such episode again. She was also suffering from chest pain on exertion for last 1yr.

Questions: 1.Anymore clarification in the history? 2.What is the provisional diagnosis? Why? 3.What is the reason for SOB in the late hours of night? 4.What is the cause of hemoptysis? 5.What is the cause of palpitation? 6.What is the cause of transient weakness of left upper limb? 7.What is the cause of chest pain on exertion? 8.What is the cause of fever?

On examination her pulse was 84bpm, of good volume with a rapid upstroke. Her blood pressure in the right upper limb was 110/60/0 mm of Hg and right lower limb 160/64/0 mm of Hg. Cardiovascular examination revealed the followingPalpation: Apex- left 6th inter-costal space 2.5cm outside the mid-clavicular line. Left parastenal pulsation present Auscultation: S1 P2 ?OS+ / ?LV S3 + Mitral Area- Pan-Systolic Murmur Gr.III/VI on Handgrip Mid-diastolic rumbling Murmur on Handgrip Pulmonary Area Ejection Systolic Murmur Gr.II/VI Aortic Area & Neo-Aortic Area Ejection Systolic Murmur Gr.II/VI Radiating to both carotids ; on Handgrip
Early Diastolic Murmur occupying 2/3rd of diastole ; on Handgrip Abdomen- Spleen just palpable

Questions: 1.Any more clarifications ? 2.How to differentiate between OS and LV S3 ? 3.What is the final diagnosis ? 4.Which lesion is predominant ? 5.Is ESM in aortic area due to AS or AR alone ? 6.Can all the findings be explained by severe AR? 7.What are the peripheral signs of AR ? 8.Can MDM be the Austin-Flint murmur?

ECG- LVH with diastolic strain CXR- Cardiomegaly

CASE 2:
40 yrs old female presented with progressive SOBE and easy fatiguability of 3yrs duration. She had SOB on unaccustomed activities initially but at present she was breathless even on routine activities.She frequently suffered from cough and cold. She also had palpitations over last 2 yrs which increased on exertion. She was hypertensive controlled on medication and euglycemic. She was married with two children. Both the deliveries were uneventful.

Questions: 1.What is the probable diagnosis from the history 2.What is the cause of late presentation of symptoms 3. Can only hypertension be responsible for her symptoms? 4. Why she was not symptomatic during pregnancy?

On physical examination her pulse was 84bpm irregularly irregular.Her blood pressure was 140/90 mm of Hg. JVP was of normal height and the A wave is equal to the V wave. Cardiovascular examination revealed the followingPalpationApex Left 5th intercostals space just outside the MCL line; diffuse in character Left parasternal lift present Pulmonary pulsation present with a systolic thrill. AuscultationS1 loud S2 loud. ? Wide split/? OS Mitral Area MDM Pulmonary Area ESM Grade IV/VI on inspiration

Questions: 1. Why A wave is is equal to V wave? 2. Is systolic thrill consistent with this condition? 3. What is the mechanism of wide split in ASD? 4. What will be the ECG & X-Ray findings in this condition ? 5. Which investigation will be confirmative? 6. What will be the management for this condition role of device therapy or surgery?

CASE No.3:
12yrs male presented with history of bluish discolouration of nails and squatting for last 7yrs. His mother told that he suffered from blue spells frequently on crying,feeding or bowel movement during the 1st year of life. She also said that he had delayed milestones of development. The birth of the child was uneventful.He had two other siblings who were normal.

Questions: 1.What is the probable diagnosis? 2.Why the symptoms and signs do not occur immediately after birth? 3.What is cyanotic spell and why it occurs?

On physical examination he was underdeveloped. His pulse was 84 bpm, normal in character.His blood pressure was 120/80 mm of Hg. His JVP was normal. Cardiological examination revealed the following PalpationApex- Left 5th Intercostal space on the Mid-Clavicular line. Lower left parasternal and sub-xiphoid pulsations present. AuscultationS1 normal S2 loud and single. Pulmonary Area and Left 3rd Intercostal spaceESM grade III/VI on handgrip.

ECG P-pulmonale RAD RVH with strain CXR Normal pulmonary vascularity Normal cardiac size Upturned apex

Questions: 1.Can this be Eisenmengers Syndrome? 2.Can this be severe valvular PS with reversal of shunt through PFO ? 3.What are the typical anatomical components in this condition? 4.What is the developmental basis for this disease? 5.What are the typical findings of this condition ? 6.What is the investigation to confirm the diagnosis ? 7.What is the medical management for cyanotic spells? 8.What is the surgical management- palliative and corrective? 9.What are the complications of TOF?

CASE No.4
19yrs old female presented with Syncope and chest pain on exertion and shortness of breath with mild exertion. Her symptoms started early childhood and was detected to have cardiac problems during early childhood with frequent cough and cold.

Questions: 1.What type of heart disease is present in this patient? 2.What is the probable diagnosis? 3.What is the mechanism of syncope and chest pain? 4.Why not it is Tetralogy of Fallot ?

Physical Examination:Slender appearance with dusky skin Cyanosis, clubbing hands and feet; Pulse: 88/bpm regular; BP: 110/70 mmhg Peripheral pulses normal. JVP: 9 cms with prominent a wave. Left parasternal heave; S1- Normal, S2- Loud and single. Ejection click over the pulmonary ares. Chest and abdominal examination : normal.

Investigation:-

ECG, X-Ray Chest:PA , Echo cardiogram (Done) Arterial O2 Sat 75% , Hb: 21gms/dl; Haematocit : 62%

Questions:

1.What is the correct diagnosis? 2. Is cardiac catheterisaton nessecery? 3.What is the outcome of pregnancy and foetal health? 4.What is the management of this condition medical /surgical or anything else?

CASE No.5
A 21 yr old male came to the hospital OPD for upper respiratory tract infection and incidentally found to have hypertension but without any medications. He denies any chest pain, dysponea, palpitations or syncope. There is no other remarkable history.

Questions: What is the probable diagnosis in this patient?

Physical Examination: Normal in appearance; no Cyanosis or clubbing; BP: 158/100mmhg; JVP- normal Cardiac impulse- normal S1- normal; S2- normal; S4 present Ejection Click over the aortic area Grade II/ VI ejection systolic murmur heard along left parasternal area No diastolic murmur heard. Chest and abdominal examination unremarkable. A soft continuous murmur over the back Femoral pulses in both lower limbs diminished and delayed. Optic fundas- normal

Questions: 1.What is the cause of diminished femoral pulses? 2.What is the cause of the murmur at the back? 3.What can be found on inspection and palpation of the back ? 4.What is the anatomical basis for this finding? 5.What further investigations need to be done? 6.What are the typical findings in X-Ray Chest:PA view? 7.What is the role of MRI in this condition? 8.What is the role of cardiac catheterisation in this patient? 9.What are the treatment option modes- Medical/ Balloon Aortoplasty/ Surgical repair? 10.What is the chance of Residual hypertension after intervention or surgical correction?

THANK YOU