Mitral Stenosis Case presentation

1. 1. Dr.ChinmoySaha M.D. (Cardiology) Phase B Resident

2. 2. 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
3. 3. Shortness of breath for 2 months.  Easy fatigability for the same
duration.
4. 4. 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.
5. 5. He also complains easy fatigability after exertion for the same duration
which is progressively worsening.
6. 6. 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.
7. 7. 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.
8. 8. No history of childhood fever with joint pain.
9. 9. He comes from a low socio economic family. He lives in paka house and
use sanitary latrine.
10.10. He has three sisters.  Parents are alive.  No such illness runs in his
family.
11.11. He could not mention properly.
12.12.Tab.Phenoxymethyl penicillin 250mg 1+0+1 Tab.metoprolol 25 mg
½+0+½
13.13. Appearance: ill looking  Body built: average  Co-operation:
cooperative  Decubitus: On choice Anaemia: absent  Jaundice: absent 
Cyanosis: absent Koilonychia: absent Leukonychia: absent
 14.14. 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
15.15. 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 midclavicularline,tapping in nature  Right
parasternal heave is present Palapable P2 is present
16.16. 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
17.17. Reveals no abnormality
18.18. Mitral stenosis with pulmonary HTN
19.19. Tricuspid stenosis
20.20. 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
21.21. Chronic rheumatic heart disease with moderate mitral stenosis with
pulmonary hypertension
22.22. Medical Therapy  Intervention -PMV  Surgery 1.CMC 2.OMC
3.Mitral Valve replacement
23.23. 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.
24.24. 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
25.25.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
26.26. Thank You

Mitral Stenosis (Case Presentation)

1. 1. Case Presentation By : Azhan Jamal IqraNurieSabeenJaved Syed

Haris Mustafa  Muhammad Hasan CPC 11th August 2017
2. 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. 3. PRESENTING COMPLAIN: Fever for 3 months Cough for 3 months
SOB for 3 months
4. 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
5. 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
6. 5. SYSTEMIC REVIEW: CARDIOVASCULAR SYSTEM: SOB -----------
+ve Chest Pain ------- +vePalpatations -------- +ve Edema ------------- -ve
RESPIRATORY SYSTEM: Cough -------- +ve Sputum ------- -ve
Hemoptysis -------- -ve Wheezing --------- -ve
7. 6. GASTROINTESTINAL TRACT: Nausea ------ -veVommiting -------- -ve
Diarrhea ----------- -ve URINARY SYSTEM Dysuria ------- -ve Burning
Micturation ----ve Polyuria ----------- -ve CENTRAL NERVOUS SYSTEM:
Weakness -------- +ve Vertigo ---------- -ve Headache ------- -ve Fits -------- -
ve
8. 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
9. 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
10.9. EXAMINATION
11.10. 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
12.11. 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
13.12.Dupuytren’s contracture: Absent Janewaylesion : 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
14.13. SYSTEMIC EXAMINATION: 1.
CARDIOVASCULAREXAMINATION: A) 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)
15.14. PALPATION: 1.Apex beat is palpable in 6th 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.
16.15. 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 6th intercostal space at midclavicular line.
Chest is moving symmetrically on both sides. Chest expansion is normal.
Vocal fermitus is normal.
17.16. PERCUSSION: Percussion note is resonant and equal on both sides.
Upper border of liver is in right 6th intercostal space. AUSCULTATION:
Breath sounds are vesicular and of normal intensity. No added sounds heard.
Vocal resonance is normal and equal on both sides.
18.17. 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,scarmark,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.
19.18. PERCUSSION: Shifting dullness absent. AUSCULATION: Bowel
sounds audible and of normal intensity. No bruit or friction sound audible.
20.19. CENTRAL NERVOUS SYSTEM EXAMINATION: 1) HIGHER
MENTAL FUNCTION: Patient is alert and co operative. He is well oriented
in time,place and person. Behaviour is normal.Thereare 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.
21.20. 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)
22.21. Differential Diagnosis • Mitral Stenosis due to Rheumatic Heart Disease
• Atrial Septal Defect • Systemic Lupus Erythematosus • Infective
Endocarditis
23.22. INVESTIGATIONS • CBC • ESR • ASOT • C-XRAY • ECG • ECHO
24.23. MANAGEMENT
25.24. How this patient was managed in Fatima hospital? 1) Augmentin 1.2
gms IV which was followed by B.D orally. 2) Panadol x 2 B.D 3) Nub with
Atrovent (Ipratropium) 4) Carveda (B-blocker) 6.25 mg B.D 5)
Lasik( Furosemide) 20mg O.D After we observed him for few days, we
refered him to NICVD for his further treatment.
26.25. MANAGEMENT: Patient with minor symptoms should be treated
medically,but the definitive treatment is surgical. MEDICAL
MANAGEMENT: 1. Sodium restriction and diuretics for pulmonary edema
and congestion. 2. In Atrial fibrillation: B-blocker, calcium channel blockers
or digoxin ( 0.125-0.25 mg/day) for rate control. 3. 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.
27.26. BALLOON VALVULOPLASTY: This will be performed if the
following criteria is fulfilled. 1. Significant symptoms 2. No mitral
regurgitation 3. Mobile non-calcified valves 4. 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.
28.27. SURGICAL MANAGEMENT: Following surgical options are available:
1) 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.
1. . PercutaneousTransluminal Coronary Angioplasty <br />(PTCA)<br />Coronary Artery Bypass Graft
(CABG)<br />By Theodoros Adoni 1151 <br />
2. 2. PercutaneousTransluminal Coronary Angioplasty (PTCA)<br /><ul><li>Is performed to open blocked or
narrowed coronary arteries caused by coronary artery disease (CAD) and to restorearterial blood flow to the
heart tissue without open heart surgery
3. 3. Greek word ‘αγγείο’ = vessel</li></ul>and ‘πλαστός’ = moulded<br />
4. 4. Causes<br /><ul><li>Coronary artery disease (CAD) occurs when fatty deposits called plaquebuild up
inside thecoronary arteries</li></ul>Factors:<br /><ul><li>Smoking
5. 5. High amounts of certain fats and cholesterolin the blood
6. 6. High blood pressure
7. 7. High amounts of sugar in the </li></ul> blood due to insulin resistance or <br /> diabetes<br />
8. 8. Symptoms<br />- Chest pain (angina pectoris) - due to lack of oxygen<br />- Difficulty breathing or
shortness of breath <br />- Sweating or “cold sweat” <br />- Fullness, indigestion, or choking feeling (may
feel like “heartburn”) <br />- Nausea or vomiting<br />- Dyspnea<br />- Excessive fatigue<br />
9. 9. PTCA Procedure<br /><ul><li>A special catheter is inserted into the coronary artery to be treated in the
femoral artery in the groin
10. 10. First a guide wire is inserted and then a catheter which injects a dye</li></li></ul><li>PTCA Procedure –
Balloon<br /><ul><li>This catheter has a tiny balloon as its tip
11. 11. The balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery
12. 12. The inflation of the balloon </li></ul>compresses the fatty tissue in the <br />artery and makes a larger
opening inside the artery for improved <br />blood flow<br />
13. 13. PTCA Procedure – Stent Placement<br /><ul><li>Is a procedure used in PTCA
14. 14. A tiny, expandable </li></ul> metal coil (stent) is <br /> inserted into the newly<br /> opened area of the
<br /> artery to help keep the<br /> artery from narrowing <br />or closing again<br />
15. 15. PTCARisks of the Procedure<br /><ul><li>Bleeding at the catheter insertion site </li></ul> (usually
groin)<br />- Blood clots or damage to the blood vessels at the insertion site<br />- Blood clot within the
vessel treated by PTCA/stent<br />- Infection at the catheter insertion site<br /><ul><li>Cardiac
arrhythmia</li></ul>- Chest painor discomfort<br />- Rupture of the coronary artery<br />
16. 16. PTCA Procedure monitoring<br />Fluoroscopy (a special type of x-ray that obtains real- time moving
images) assists the physician in the location of blockages in the coronary arteries as the contrast dye moves
through the arteries.<br />
17. 17. Coronary artery bypass graft (CABG)<br />CABG is used over angioplasty when…<br /><ul><li>
patientswith severe narrowing or blockage of the left main coronaryartery
18. 18. patients with disease involving two or three coronaryarteries are generally considered for bypass
surgery</li></li></ul><li>Coronary artery bypass graft<br />A segment of a healthy blood vessel from
another part in the body is taken <br />and make a detour around the blocked part of the coronary
artery<br />Vessels are used:<br />- Internal thoracic artery<br /> - Saphenous vein<br />- Radial
artery<br />
19. 19. CABG procedure<br />-Incision is made in chest wall (sternotomy)<br />-Bypass grafts are harvested<br
/>-In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart<br />-In the case is
"on-pump", surgeon connects<br />heart lung machine to patient and delivers <br />cardioplegia to stop the
heart<br />
20. 20. <ul><li>One end of each graft is sewn on to </li></ul>the coronary arteries beyond the <br />blockages
and the other end is <br />attached to the aorta.<br />
21. 21. - Internal defibrillator paddles used to induce pulse<br />
22. 22. The End<br />