Alfelor, RemelouAlfelor, Remelou

04/18/23 1

• 30 year old male • Filipino• General manager of Jollibee• CHIEF COMPLAINT:

Difficulty of BreathingDifficulty of Breathing

04/18/23 2

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

04/18/23 3

SALIENT FEATURESSALIENT 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

• (+) 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

• (+) 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)*

• (+) 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)*

04/18/23 4

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

• General Survey: conscious, coherent, ambulatory, very anxiousvery anxious• Vital Signs: – BP=90/60, HR=102/min (irregularly irregular)BP=90/60, HR=102/min (irregularly irregular)– RR= 24/minRR= 24/min, Temp: 36.8oC– Weight: 46 kg, Height: 155cm, BMI= 19.0

• HEENT: pink palpebral conjunctivae, no cervical lymphadenopathy– icteric scleraeicteric sclerae

• Skin: good skin turgor, no lesions• Neck: no carotid bruits, brisk upstroke of carotid pulse, – JVP=5 cm at 30JVP=5 cm at 30oo

• General Survey: conscious, coherent, ambulatory, very anxiousvery anxious• Vital Signs: – BP=90/60, HR=102/min (irregularly irregular)BP=90/60, HR=102/min (irregularly irregular)– RR= 24/minRR= 24/min, Temp: 36.8oC– Weight: 46 kg, Height: 155cm, BMI= 19.0

• HEENT: pink palpebral conjunctivae, no cervical lymphadenopathy– icteric scleraeicteric sclerae

• Skin: good skin turgor, no lesions• Neck: no carotid bruits, brisk upstroke of carotid pulse, – JVP=5 cm at 30JVP=5 cm at 30oo

04/18/23 7

PHYSICAL EXAMINATIONPHYSICAL 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(+) fine basilar crackles on both lung fields• Cardiac:(+) RV heave(+) RV heave, no thrills, apex beat at the 5apex beat at the 5thth ICS 2 cm ICS 2 cm

lateral to the left midclavicular linelateral to the left midclavicular line, loud S1 at apexloud S1 at apex, prominent P2 at the baseprominent P2 at the base, , (+) gr 3/6 middiastolic rumble (+) gr 3/6 middiastolic rumble at apexat apex

• Extremities: (+) gr 1 bipedal edema(+) gr 1 bipedal edema, dorsalis pedis pulse (+2), no clubbing, no cyanosis

• 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(+) fine basilar crackles on both lung fields• Cardiac:(+) RV heave(+) RV heave, no thrills, apex beat at the 5apex beat at the 5thth ICS 2 cm ICS 2 cm

lateral to the left midclavicular linelateral to the left midclavicular line, loud S1 at apexloud S1 at apex, prominent P2 at the baseprominent P2 at the base, , (+) gr 3/6 middiastolic rumble (+) gr 3/6 middiastolic rumble at apexat apex

• Extremities: (+) gr 1 bipedal edema(+) gr 1 bipedal edema, dorsalis pedis pulse (+2), no clubbing, no cyanosis

04/18/23 8

Additional PE that should be done:Additional PE that should be done:Additional PE that should be done:Additional PE that should be done:

• Presence of oral ulcers• Mitral Facies• Joint tenderness• Subcutaneous nodules• Abdominal exam• Neurologic exam

• Presence of oral ulcers• Mitral Facies• Joint tenderness• Subcutaneous nodules• Abdominal exam• Neurologic exam

04/18/23 9

04/18/23 10

Other PE findings to be done:Other PE findings to be done:

• Presence of oral ulcers• Mitral facies• Joint tenderness• Subcutaneous nodules• Abdominal exam• Neurologic exam

• Presence of oral ulcers• Mitral facies• Joint tenderness• Subcutaneous nodules• Abdominal exam• Neurologic exam

04/18/23 11

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Mitral Valve Disease– Mitral Stenosis– Mitral Regurgitation

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

MITRAL VALVE STENOSISMITRAL VALVE STENOSIS

• Mitral Valve Disease– Mitral Stenosis– Mitral Regurgitation

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

MITRAL VALVE STENOSISMITRAL VALVE STENOSIS04/18/23 12

DIAGNOSTICSDIAGNOSTICS

04/18/23 13

LABSLABS LABSLABS

CBC FBS: 80•Hgb 12 Creatinine: 1.0•Hct 0.48 Na 142, K 3.5, SGPT 40•WBC 10 •seg 55% Urinalysis: •lympho 45% Spec grav 1.030•plt 230,000 (-)sugar, WBC, RBC

CBC FBS: 80•Hgb 12 Creatinine: 1.0•Hct 0.48 Na 142, K 3.5, SGPT 40•WBC 10 •seg 55% Urinalysis: •lympho 45% Spec grav 1.030•plt 230,000 (-)sugar, WBC, RBC

Additional DiagnosticsAdditional DiagnosticsAdditional DiagnosticsAdditional Diagnostics

• 2D Echocardiography• Holter Monitoring

• 2D Echocardiography• Holter Monitoring

04/18/23 17

04/18/23 19

DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS

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

Mitral Valve StenosisMitral Valve Stenosis3) Physiologic Disturbances:

Right Congestive Heart FailureRight Congestive Heart Failure

4) Functional Disability: NYHA Class IVNYHA Class IV

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

Mitral Valve StenosisMitral Valve Stenosis3) Physiologic Disturbances:

Right Congestive Heart FailureRight Congestive Heart Failure

4) Functional Disability: NYHA Class IVNYHA Class IV

04/18/23 20

Pathophysiology

PathophysiologyPathophysiology

PathogenesisAssociated signs and

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

LA fails to empty blood to LVLA enlarges

(+)LA enlargement on radiograph

Decrease LV filling = decrease CO (+)Easy fatigability, Dyspnea on exertion

Increase pressure in pulmonary veins

PathophysiologyPathophysiologyPathophysiologyPathophysiology

PathogenesisAssociated signs and

symptomsLA failure causes pulmonary hypertension

and edema(+)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 to pulmonary vessels

(+)RV heave, (+)possible RV enlargement on 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

PathophysiologyPathophysiologyPathophysiologyPathophysiology

PathogenesisAssociated Signs and

SymptomsRA unable to pump blood to RV due to

increase pressure in the RV. RA soon fails

Right heart failure causes pooling of blood to the venous side of the circulation

(+)grade 1 bipedal edema

MITRAL STENOSIS: MITRAL STENOSIS: ManagementManagement

MITRAL STENOSIS: MITRAL STENOSIS: ManagementManagement

Goals of Medical Treatment:

1.Prevention / Treatment of Complications2.Monitor3.Prevention of recurrent infection

Goals of Medical Treatment:

1.Prevention / Treatment of Complications2.Monitor3.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.

• 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

• Natural History–Warfarin for AF or thromboembolism–PCN for RF prophylaxis

• Mitral valvotomy is indicated in symptomatic [New York Heart Association (NYHA) Functional Class II–IV]

– 2 ways: PMBV and Surgical Valvotomy

• Mitral valvotomy is indicated in symptomatic [New York Heart Association (NYHA) Functional Class II–IV]

– 2 ways: PMBV and Surgical Valvotomy