CASE REPORT CARDIOLOGY DEPARTMENT

HASANUDDIN UNIVERSITY

MITRAL STENOSIS SEVERE

Presented by
ANGGA PRASETYA
C 111 11 905

Supervisor

dr. Yulius Patimang, Sp.A(K), Sp. JP , FIHA

 PATIENT IDENTITY
• Name : Mr. PM
• Birth Date : March, 3rd 1994
• Gender : Man
• Occupation : Employees
• MR : 837521
• Date of Admission : March, 23rd 2018
 HISTORY TAKING
• Chief complaint : Shortness of breath
• Present Illness History
It was felt since 1 week ago, when do some activity and rest. In the night, patient

always awakened because his shortness of breath and must to use two pillows for

reduce his complaint. Pulse sometimes felt. There is a chest pain. Cough (+) with

white muccous. Nausea and vomit sometimes felt. Fever (-). Defecation and urination

is normal
 HISTORY TAKING
Past history :
• History of Hypertension and DM ( - )
• History of shortness of breath (+) and high fever
frequently (+) when patient was kid
• History of family with same disease (-)
 PHYSICAL EXAMINATION
• General Status : Severe – illness / Well nourished/ Compos mentis
• Vital Sign
• BP : 110/80 mmHg
• HR : 72 bpm, reguler
• RR : 26x / min
• T : 36,7oC ( axilla )

• Head Examination
• Head : Normocephalic
• Conjungtiva : Anemic (-), icteric (-)
• Pupil : Equal, round, diameter OD/OS 2,5 mm, Light
Reflex ( direct (+/+), indirect (+/+)
• Nose : normal, no deviation
• Lips : no cyanosis
• Neck : JVP R+3 cmH2O
 PHYSICAL EXAMINATION
• Thoracic Examination
• Inspection : Symmetric between left and right
• Palpation : No mass, no tenderness
• Percussion : Sonor between left and right chest, Lung-liver junction right
ICS 6
• Auscultation : Respiratory Sound : Vesiculer
Additional Sound : Rh+/+ Minimal basal, wh-/-
• Cardiac Examination
• Inspection : Ictus Cordis visible
• Palpation : Ictus Cordis Palpable, thrill (+)
• Percussion : Left Heart Border : ICS VII linea axillaris anterior sinistra
Right heart border : ICS II parasternalis dextra
• Auscultation : Irreguler of I/II Heart Sound, diastolic heart murmur in the
apex of the heart
 PHYSICAL EXAMINATION
• Abdominal Examination
• Inspection : Flat
• Palpation : No mass, no tenderness, liver and
spleen impalpable
• Percussion : Tympany
• Auscultation : Peristaltik sound (+) normal
• Extremities
• Pretibial edema : (-/-)
• Dorsal Pedis edema : (-/-)
ELECTROCARDIOGRAPHY

Rhytm : Asinus
HR : 75x/i
Regularity : Iregular
Axis : right deviation
P wave : not visible
Interval P-R : -
QRS rate : 0,6-0,10 s
QRS Complex : normal
ST Segment : normal
T wave :-
Conclusion
Asinus, HR 75 x/i, irreguler,Atrial
fibrilation
 LABORATORY RESULTS

TEST RESULT NORMAL VALUE

TEST RESULT NORMAL VALUE

WBC 7,91 x 10^3/uL 4.0 – 10.0 x 103

Ureum 22 10-50
RBC 4,54 x 10^6 4.0 – 6.0 x 10 6

HGB 14,0 g/dL 12 – 16

Creatinin 0,86 0,5-1,2

HCT 41,6 % 37 – 48 Natrium - 136 - 145

PLT 224 x 103/uL 150 – 400 x 103

Kalium - 3,5 - 5,1
PT 13,4 10 - 14
36,0
Chloride - 97 - 111
APTT 22,0 - 30,0

INR 1,25  

GDS 122 140

SGOT 58 u/L <38

SGPT 92u/L <41

RADIOLOGY FINDING
• Cardiomegaly
• Lung edem suspect
pericard efusion
 ECHOCARDIOGRAPHY

Conclusion
• Good function of left ventricular, EF 65,3%
• Dilatation of LA,RA,and RV
• Sufficient function of right veentricular systolic
• MS severe,MR severe,AR mild,TR severe
• High probability of PH
• Pericardial efusion mild-moderate
 DIAGNOSIS
• Mitral Stenosis Severe
• Mitral Regurgitation
• Efusi Pericardium
• Atrial Fibrilation
• Congestive Heart Failure
 TREATMENT
• Furosemide inj 40 mg/ 8 hours/ IV • Simarc 2 mg/24 hours/Oral
• Spiranolactone 25 mg/24 hours/oral • N-Ace 200mg/8 jam/Oral
• Ceftriaxone 2gr/24 jam
• O2 4 LPM via nasal kanul • Ambroxol 30 mg/8 jam/oral
• Digoxine 0,25mg/IV/bolus pelan
• IVFD NaCl 0,9% 500cc/24 jam
DISCUSSION
 DEFINITION
Mitral stenosis is a condition that blood from left
atrium can’t enter the left ventricle caused by there
is a structural abnormality from the mitral valve and
causes the mitral valve can’t open completely when
in diastolic phase
 ETIOLOGY
• Most Common : Rheumatoid Fever
• Other causes :
– Bacterial endocarditis
– Congenital malformation
– atherosclerosis
PATHOPHYSIOLOGY
 SIGN AND SYMPTOM
• Tachycardia
• Dyspneu
• Tachypneu
• Ortopneu
• Paroxysmal nocturnal dyspneu
• Uncontroled heartbeat
• Hemoptisis
 PHYSICAL EXAMINATION
• Malar flush
• Tiny face and bluish
• Strong JVP
• Peripheral cyanotic
• Auscultation : murmur mid-diastolic, opening snap, Ronkhi
• Hepatomegaly
• Ascites
• Edem extremities
ECG
 IMAGING
• CHEST X-RAY
• ECHOCARDIOGRAPHY ( GOLD STANDARD )
 MANAGEMENT
• Non medication • Operation
– Salt restriction
– Fluid restriction
– Open Mitral commissurotomy
– Avoid smoking and alcohol – Valve Replacement
– Exercise routinely
• Medication
– Antibiotic prophylaxis
– Diuretic
– Nitrat
– Digoxin
– Beta Blocker or calcium channel blocker
– anticoagulan