Cardiovascular system

Case discussion
Prof. Abdul majeed
Case 1
• A 65 years male from Perambra, retired teacher presented to our ER dept with
shortness breath and cough of acute onset. No chest pain or dizziness+.
He gives history of grade 2 (NYHA) exertional dyspnoea for 6 months, following
acute MI treated conservatively. No angina and no syncope on exertion in past.
He is ex-smoker stopped 1 year back. No history of diabetes or dyslipidemia. He
has 2 brothers and 1 sister, healthy.
General examination
• Examination reveals an elderly male, who is anxious, restless and
dyspnoeic, sitting on the bed, getting nasal oxygen
• No pallor or cyanosis or edema of ankles. Neck veins not distended
Pulse 104/mt, with 2-3 missed beats per/mt, volume is adequate and
no abnormal character. All peripheral pulses felt equally on either side
• BP 150/90mm Hg in sitting position
• Respiratory rate 24/mt and patient is afebrile
• JVP is not elevated
Cardiovascular system
• Inspection of precordium
Shape of chest is normal, no precordial bulge, apex beat visible in 6th left IC space
outside MC line, no pulsations over the aortic, pulmonary or left parasternal areas.
No other pulsations or prominent vessels on the chest, no scars of previous surgery.
• Palpation
Apex beat is palpable and position confirmed in left 6 th IC space 1 cm outside MC
line, normal in character, no thrill or no left parasternal heave or other pulsations felt
over the precordium. No epigastric pulsation.
Continued
• Percussion not done, as ACS suspected
• Auscultation
Over the mitral area S1 is soft and S2 heard with normal intensity. There is a soft
blowing pansystolic murmur heard (gr 3/6) and S3 is audible. S1 and S2 heard over other
areas and no other cardiac murmur.

• Respiratory system
Shape of chest normal, both sides moving equally, vocal fremitus – not done, patient
not able to cooperate,
Percussion note is resonant. Breath sounds vesicular, well heard on both sides,
crepitations present over the lung bases- the infra-scapular, infra-axillary and mammary
areas
• Abdomen is soft to palpate, non tender moves well on respiration,
no enlargement of liver or spleen, no free fluid in abdomen
• Nervous system: detailed examination not done. Patient is conscious,
able to communicate, No focal neurological deficit.
Provisional diagnosis

• Ischemic heart disease, Left ventricular failure and Mitral

regurgitation (papillary muscle rupture likely), Ectopic beats present
• Acute pulmonary edema, ACS to be considered as the precipitating
factor
• Risk factors Male sex and Age, Ex smoker
Discussion
• This patient has symptoms of LV failure, exertional dyspnoea of 6 months
following acute MI. Now he has come with severe breathlessness and cough,
likely due to Acute pulmonary edema. Patient is orthopnoeic and in respiratory
distress. sometimes patient may cough out pink frothy sputum. The
precipitating factor could be an acute coronary event though patient has no
chest pain. Other causes include arrhythmia or undue exertion or infection
• Soft blowing murmur and LV S3 in mitral area suggest Mitral regurgitation, likely
due to papillary muscle rupture from ischemia. It may be a previous lesion or
recent one leading acute LVF and pulmonary edema
Hence look for ECG changes acute MI or Arrhythmia, monitor Troponin I levels
and Echo evidence of Regional wall motion abnormality.
Discussion Continued
• Clinical signs of LV failure include Sinus tachycardia often with ectopic
beats, orthopnoea, cardiomegaly, S3 gallop rhythm, soft mitral
blowing murmur. Crepitations over the lung bases or diffusely
depending on severity. Other signs of underlying cardiac condition like
Aortic valve disease may be there.
Assignments –
• Learn method of taking history, writing examination findings and
writing provisional diagnosis
• Management of acute pulmonary edema due to left heart failure
• Diagnosis and management of Acute myocardial infarction, in acute
setting and follow up care
• Complications of Ischemic heart disease
• Modifiable risk factors of Coronary artery disease
• Ventricular arrhythmias and management
Case 2
• A 30 years female, mother of 2 children presented with palpitation
and breathlessness of 5 years, the symptoms have progressed during
last 6 months. She gives history painful swelling of joints at 15 years
of age and she was hospitalized once with severe breathlessness
following an acute respiratory infection. Initially he took some
monthly injections for 5 years and stopped. No history of Bronchial
asthma. She was apparently well during pregnancy and labour. LCB is
8 years.
• Personal and family history non contributory.
Examination findings
• A thin built young lady, sitting comfortably, not breathless. No pallor
cyanosis or clubbing of fingers, pedal edema present.
• Vital signs
Pulse 100/mt, totally irregular, varying in volume and rhythm, pulse
deficit of 12 beats/mt, no collapsing character, peripheral pulses
present except left post tibial and dorsalis pedis. BP 110/70 , Resp. rate
20 breaths/mt and afebrile
• JVP is elevated, (examined sitting upright for want of adjustable bed)
7cm above sternal angle
Examination of precordium

• Inspection : Shape of chest normal, no bulging, apex beat seen in 5th

IC space 1 cm lateral to MC line
• Palpation confirmed position of apex beat, normal in character, a
diastolic thrill felt is over apex, other signs include left parasternal
heave and P2 is palpable over pulmonary area.
• Percussion cardiac dullness within normal limits, no cardiac dullness
detected beyond right sternal margin.
• Auscultation:
Mitral area - S1 is soft, a rough rumbling, low pitched mid diastolic
murmur is heard, better on turning the patient to left side,
also a soft blowing, high pitched systolic murmur present in mitral
area with conduction towards axilla.
P2 component of S2 is loud in pulmonary area. Heart sounds well
heard in other areas, no other murmur
Examination Continued
• Respiratory system
Shape of chest normal, no shift of trachea, chest movements equal on either side,
normal vocal fremitus, resonant note over the lungs, breath sounds vesicular and
heard well on both sides, fine crepitations over infra-axillary and insfra-scapular areas.
• Abdomen
Partly distended, soft and non tender, liver is palpable 3cm below right costal
margin, soft and tender, spleen not palpable and no free fluid, (no shifting dullness or
fluid thrill). Bowel sounds normal
• Nervous system
Patient is conscious and alert, higher functions, cranial nerves, motor system and
sensations Normal,no focal Neuro deficit
Provisional diagnosis

• Rheumatic heart disease / mitral stenosis and mitral regurgitation,

• Complications - Pulmonary arterial hypertension, Congestive cardiac
failure, Atrial fibrillation and Peripheral artery embolism (Right lower
limb)
Discussion
• This young lady suffers from Rheumatic Herat disease as sequale to
Rheumatic fever at age of 15 years. She suffered from poly arthritis
(one major criterion) and she was advised Penicillin prophylaxis to
prevent further episodes.(monthly injections for 5 years).
• Her symptoms of exertional dyspnoea and palpitation result from
mitral valve disease causing elevated left atrial pressure, leading to
pulmonary venous congestion and edema. Hemodyanamic
disturbance occurred gradually after initial attack of Rheumatic fever.
She was asymptomatic during her 2 pregnancies and deliveries.
• Mitral stenosis results as a sequele to Rheumatic fever and may be
associated with mitral regurgitation, if cusps are deformed, fibrosed
or calcified.
Mitral stenosis leads to a mid diastolic rough rumbling murmur, low
pitched with presystolic accentuation (if no atrial fibrillation), the
classical description. There may be an opening snap sound preceding
the murmur and S1 is loud.
Mitral regurgitation: you hear a blowing pan systolic murmur, high
pitched over the mitral area and this murmur may radiate to axilla, S1 is
soft as mitral valve is damaged and there is mitral regurgitation.
• Atrial fibrillation is a common arrhythmia seen with mitral valve
disease and leads to worsening of cardiac failure, thromboembolism
(arterial embolism right lower limb) and palpitation as an important
symptom. Clinically suspected from totally irregular pulse, pulse
deficit and irregular cardiac rhuthm on auscultation. Similar signs may
occur with frequent irregular ectopic beats.
• Chronically elevated left atrial pressure leads to changes in pulmonary
vessels, causes pulmonary arterial hypertension and right failure.
• Signs of pulmonary arterial hypertension include giant a waves in JVP,
left parasternal heave and loud P2 (pulmonary component of S2). In
severe cases there may be tricuspid regurgitation due to dilatation of
valve ring - the signs include soft blowing pansystolic murmur in
tricuspid area, better during inspiration, presence expansile v wave in
JVP and pulsatile liver.
• She has signs of cardiac failure like elevated JVP, soft hepatomegaly
and pedal edema, along with pulmonary basal crepitations.
Learning objectives
• Learn how to take history, detect clinical signs, make provisional
diagnosis and discuss the patient problems/
• Rheumatic fever criteria for diagnosis, clinical signs and treatment
• Rheumatic fever prophylaxis
• Pulmonary Arterial hypertension, causes Cardiac and noncardiac,
Clinical signs
• Cardiac failure – left heart failure and right heart failure, diagnosis and
principles of management