Alfelor, Remelou

09/10/15

30 year old male

Filipino
General manager of Jollibee
CHIEF COMPLAINT:

Difficulty of Breathing

09/10/15

HISTORY OF PRESENT ILLNESS

09/10/15

SALIENT FEATURES

(+) Easy fatigability

(+) Shortness of breath when at
work
(+) Palpitations accompanied
by chest pain occurring even at
rest
Progression of symptoms
No relief with Seretide
(-) Fever
(-) Smoker

09/10/15

(+) nonproductive cough for 3

weeks esp when supine
(+) episodes of near syncope
(+) swelling of both feet
(+) maternal history of heart
disease (died at 45yrs old)*

PHYSICAL EXAMINATION
General Survey: conscious, coherent, ambulatory, very anxious
Vital Signs:
BP=90/60, HR=102/min (irregularly irregular)
RR= 24/min,
24/min Temp: 36.8oC
Weight: 46 kg, Height: 155cm, BMI= 19.0
HEENT: pink palpebral conjunctivae, no cervical lymphadenopathy
icteric sclerae
Skin:good skin turgor, no lesions
Neck: no carotid bruits, brisk upstroke of carotid pulse,
JVP=5 cm at 30o
09/10/15

PHYSICAL EXAMINATION
Lungs: equal chest expansion, no retractions, equal tactile fremitus
both lung fields, resonant to percussion on both lung fields

(+) fine basilar crackles on both lung fields

Cardiac:(+) RV heave, no thrills, apex beat at the 5th ICS 2 cm
lateral to the left midclavicular line, loud S1 at apex,
prominent P2 at the base, (+) gr 3/6 middiastolic rumble
at apex
Extremities: (+) gr 1 bipedal edema, dorsalis pedis pulse (+2), no
clubbing, no cyanosis

09/10/15

Additional PE that should be done:

Presence of oral ulcers

Mitral Facies
Joint tenderness
Subcutaneous nodules
Abdominal exam
Neurologic exam

09/10/15

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10

Other PE findings to be done:

Presence of oral ulcers

Mitral facies
Joint tenderness
Subcutaneous nodules
Abdominal exam
Neurologic exam

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DIFFERENTIAL DIAGNOSIS
Mitral Valve Disease
Mitral Stenosis
Mitral Regurgitation

Atrial Myxoma
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
PRIMARY WORKING IMPRESSION:

MITRAL VALVE STENOSIS

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DIAGNOSTICS
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LABS
CBC
Hgb 12
Hct 0.48
WBC 10
seg 55%
lympho 45%
plt 230,000

FBS: 80
Creatinine: 1.0
Na 142, K 3.5, SGPT 40
Urinalysis:
Spec grav 1.030
(-)sugar, WBC, RBC

Additional Diagnostics
2D Echocardiography
Holter Monitoring

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DIAGNOSIS
1) Underlying Etiology: Rheumatic Fever
2) Anatomical Abnormalities:

Mitral Valve Stenosis

3) Physiologic Disturbances:

Right Congestive Heart Failure

4) Functional Disability: NYHA Class IV
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Pathophysiology

Pathophysiology
Pathogenesis

Associated signs and

symptoms

Mitral Stenosis

(+)3/6 middiastolic murmur at apex, Loud S1

LA fails to empty blood to LV

LA enlarges
Decrease LV filling = decrease CO

Increase pressure in pulmonary veins

(+)LA enlargement on radiograph

(+)Easy fatigability, Dyspnea on exertion

Pathophysiology
Pathogenesis
LA failure causes pulmonary hypertension
and edema

Associated signs and

symptoms
(+)Paroxysmal nocturnal dyspnea,
progressive dyspnea, fine bibasilar crackles
on both lung fields, non productive cough,
(+)prominent pulmo vasc

Increase pressure in pulmonary arteries

RV needs to increase effort in pumping blood (+)RV heave, (+)possible RV enlargement on

to pulmonary vessels
chest X-ray causing displacement of apex
beat to 2 cm lateral to left MCL 5th ICS,
(+)Prominent P2 at base
RV contributes to pulmonary congestion and
later on fails

Pathophysiology
Pathogenesis

Associated Signs and

Symptoms

RA unable to pump blood to RV due to

increase pressure in the RV. RA soon fails
Right heart failure causes pooling of blood to (+)grade 1 bipedal edema
the venous side of the circulation

MITRAL STENOSIS:
Management
Goals of Medical Treatment:
1.Prevention / Treatment of Complications
2.Monitor
3.Prevention of recurrent infection

 Pharmacologic approach:
Symptom Control:
Beta blockers, nondihydropyridine calcium
channel blockers, or digoxin for rate control of AF
Cardioversion for new-onset AF and HF
Diuretics for HF.

 Natural History
Warfarin for AF or thromboembolism
PCN for RF prophylaxis

 Mitral valvotomy is indicated in symptomatic

[New York Heart Association (NYHA) Functional Class IIIV]

2 ways: PMBV and Surgical Valvotomy