CASE PRESENTATION

Presented by
K SAI TEJA(PG)
Moderators
Dr Ch INDIRA PRIYADARSINI MD
Professor,Unit Chief
Dr JC MADHUSUDHAN RAO MD
Assistant Professor
Dr R SURYUDU MD
Assistant Professor
 Chief complaints
A 56 yr old male named SREENIVASULU ,who
is a coolie hailing from Ramapuram, came
with chief complaints of
 Chest pain since 1 year
 Breathlessness since 9 months
 History of present illness
Patient was apparently normal 1 year back, then he
developed exertional chestpain since 1 year,which is insidious in
onset, gradually progressive,initially he had chestpain upon
walking rapidly and climbing stairs

6 months later

He developed chestpain upon walking for 100 metres at his own pace

Now he is having chestpain even when he walks to the washroom

[ around 10 metres]
• The pain is diffusely located over left side of
the chest, constricting type, radiates to left
shoulder and left arm, pain persists during the
entire period of exertion
• Pain relieves on resting for 2 minutes
• No diurnal variation
• Associated with sweating
• Not associated with
palpitations / syncopal attacks
• Not associated
with nausea / vomiting / abdominal pain
C/o breathlessness since 9 months which is insidious in onset, gradually
progressive, initially he had breathlessness upon walking
rapidly and climbing stairs

3 months later
He started having breathlessness upon walking for 100 meters

Now he is having breathlessness even when he walks upto

washroom [around 10 metres]
Relieves on taking rest within 5 minutes
Not associated with cough or wheeze
No history suggestive of orthopnoea and PND
• H/O lightheadedness since 2 months,
occasionally perceived and occurs only on
exertion , relieved on sitting on bed within
few minutes
Not associated with palpitations
• Not H/o syncopal attacks
• No history of fever
• No H/O swelling of both lower limbs

• No H/O decreased urine output/ facial

puffiness/ abdominal distension.
• No H/O blood in stools
• No H/o dysphagia / hoarseness of voice
 Past history
• No history of similar complaints in the past
• No history of hypertension/diabetes
mellitus/coronary artery disease/chronic kidney
disease/thyroid disorders/Asthma.
• No history of fever with fleeting joint pains/ rash in
childhood
• No history of recurrent respiratory tract infections
during childhood
• No history of intramuscular injections once in every
3 weeks duration
 Family history
• Born out of non consanguinous marriage
• No history of similar complaints in the family
• No history of sudden cardiac death in family
• No H/O Congenital heart diseases/CAD in
family members
 Personal history
• Bowel and bladder habits are normal
• Appetite is normal
• Sleep is normal
• Not a smoker/not an alcoholic
 Treatment history

• No significant treatment history

 summary
• A 56yr old male patient presented with exertional
chestpain since 1 year, exertional breathlessness
since 9 months, lightheadedness since 2 months
• System involved - cardiovascular system
• Probable Etiology:
• 1. Coronary artery disease
• 2. Aortic stenosis - Degenerative calcific AS/
Rheumatic AS
• 3. Anemia in failure
 General examination
• Patient is conscious ,coherent
• Moderately built and moderately nourished
• height :176cm
• weight:78kgs
• BMI:25.2kg/m2
• No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy.
• No external markers of Infective endocarditis .
• No external markers of Atherosclerosis
• No peripheral signs of Aortic Regurgitation
• No marfanoid features
• Thyroid- appears to be normal
• spine- appears to be normal
• JVP: 2cms from sternal angle ,total 7cm of blood or 5.6mm Hg
Vitals:
• Pulse: 80/min,regular, low volume, slow rising and
late peaking, associated with carotid thrill, No
vessel wall thickening ,No radio radial or radio
femoral delay, All peripheral pulses are felt equally
BP:
• 90/70 mmHg in left upper limb, supine position
• 96/70 mmHg in Right upper limb, supine position
• 100/76 mmHg in Right lower limb
• 106/76mmHg in Left lower limb
• Respiratory rate: 18 cycles/min,
thoracoabdominal type
• Temperature- 98.4F
 Systemic examination
INSPECTION:
• Chest - bilaterally symmetrical
• Trachea appears to be in midline
• Apical impulse appears to be in left 5th intercoastal
space, 1 -2 cm medial to mid clavicular line
• No parasternal and Epigastric pulsations seen.
• No other visible pulsations
• No visible scars, sinuses or engorged veins.
PALPATION:
• Trachea position is in midline
• Apex beat felt in left 5th intercoastal space 1 cm medial to
midclavicular line, heaving type. No palpable sounds or thrills in
apical area
• Systolic thrill present in right second intercostal space. No other
palpable sounds / thrills in right second intercostal space
• No palpable sounds/ thrills in left second intercostal space
• No palpable sounds/ Thrills in lower left parasternal area
• No parasternal heave
• No other pulsations / thrills
 Percussion
• Liver dullness at right 5th intercoastal space in
mid clavicular line
• Left heart border corresponds to apex
• Right heart border corresponds right sternal
margin
• Aortic area- resonant
• Pulmonary area –Resonant
 Auscultation
Mitral area:
• s1 normal , s2 heard.
• A high pitched,soft, midsystolic murmur of
Grade 3/6, best heard in expiration with the
diaphragm of stethoscope, not radiating to
axilla
• No other sounds
 Aortic area:
• S1 heard, soft s2
• A low pitched, harsh, ejection systolic murmur of grade 4/6 ,
crescendo decrescendo murmur , best heard in expiration in
leaning forward position with diaphragm of stethoscope,
with conduction to carotids
• Murmur increases on squatting
• Murmur decreases on standing, and with isometric hand grip
• No other sounds
Pulmonary area:
• s1 heard, normal s2- Normal p2
• No other sounds
NEO AORTIC AREA
• S1 AND S2 HEARD
• No other sounds
Tricuspid area:
• S1, s2 heard
• A high pitched,soft, midsystolic murmur of
Grade 3/6, best heard in expiration with the
diaphragm of stethoscope
• No other sounds
• Respiratory system-bilateral normal vesicular
breath sounds
• P/A– soft ,no tenderness,no organomegaly
• Central nervous system –bilateral pupils 2-3
mm reacting to light equally
bilateral plantar flexors
no focal neurological deficits
 Provisional diagnosis
• Chronic Acquired valvular heart disease, with
severe valvular Aortic stenosis probably due
to degenerative calcification with no signs of
heart failure
• with no signs of pulmonary hypertension, no
signs of infective endocarditis, in normal sinus
rhythm
THANK YOU