Mitral Stenosis (Case Presentation)

1. Case Presentation
By :
 Azhan Jamal
 Iqra Nurie
 Sabeen Javed
 Syed Haris Mustafa
 Muhammad Hasan
CPC 11th August 2017

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. PRESENTING COMPLAIN:
Fever for 3 months
Cough for 3 months
SOB for 3 months
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

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

5. SYSTEMIC REVIEW:
CARDIOVASCULAR SYSTEM:
SOB ----------- +ve
Chest Pain ------- +ve
Palpatations -------- +ve
Edema ------------- -ve
RESPIRATORY SYSTEM:
Cough -------- +ve
Sputum ------- -ve
Hemoptysis -------- -ve
Wheezing --------- -ve

6. GASTROINTESTINAL TRACT:
Nausea ------ -ve
Vommiting -------- -ve
Diarrhea ----------- -ve
URINARY SYSTEM
Dysuria ------- -ve
Burning Micturation ----ve
Polyuria ----------- -ve
CENTRAL NERVOUS SYSTEM:
Weakness -------- +ve
Vertigo ---------- -ve
Headache ------- -ve
Fits -------- -ve

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

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

9. EXAMINATION

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

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

12. Dupuytren’s contracture: Absent
Janeway lesion : 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

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)

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.

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. 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. 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,scar mark,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. PERCUSSION:
Shifting dullness absent.
AUSCULATION:
Bowel sounds audible and of normal intensity. No bruit
or friction sound audible.

20. 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.There are 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. 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. Differential Diagnosis
• Mitral Stenosis due to Rheumatic Heart
Disease
• Atrial Septal Defect
• Systemic Lupus Erythematosus
• Infective Endocarditis

23. INVESTIGATIONS
• CBC
• ESR
• ASOT
• C-XRAY
• ECG
• ECHO

28. MANAGEMENT

29. 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.

30. 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.

31. 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.

32. 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.

33. MITRAL STENOSIS
Subtitle

34. A clinicopathological condition characterized by
narrowing of mitral valve resulting in left atrial
hypertrophy and dilation.
CAUSES:
• Rheumatic Heart Disease (most common cause)
• Congenital
• Carcinoid Syndrome
• Bacterial vegenation
• Mitral annular calcification
• SLE

35. Class Valve area(cm2) Symptoms
Minimal >2.5 None
Mild/Moderate <2.5 - >1.-0
Dyspnea,Orthopnea
,PND,Pul Edema
Severe <1.0
Resting Dyspnea,
disabled/bed chair

36. Mitral Stenosis
Inc. Intra-atrial
Pressure
Left atrial
dilation
Pulmonary
Congestion
Pulmonary
Oedema
Right
ventricular
dilation
Right heart
failure
Inc. JVP
Anasarca

38. • Symptoms
• Dyspnea
• Palpitation
• Fatigue
• Dysphagia
• Hemoptysis
• Embolic event
• Signs
• Palpation of S1 (Pathognomonic)
• Dystolic Thrill/Mid-dystolic murmur (Left
lat. decubitus position)
• Apex beat: Localized and tapping
• Heart Sounds: S1 loud
• Opening snap
• Right parasternal heave; Pulmonary
Hypertension
• Malar facies (Blue dusky appearance on
cheeks)
• Rising JVP
• Graham-Steel murmur (Pul. HTN and
Severe MS)

39. KEY DIAGNOSIS
• Exertional dyspnea
• Paroxysmal nocturnal
dyspnea
• Orthopnea
• Fatigue
• Opening snap
• Loud S1
• Mid-Dystolic Murmur
• Pulmonary HTN
• ECG:
- Atrial Fib.
- Bifid P wave
• CXR:
- Straightening of left heart border
(left atrial enlargement)
• ECHO:
- Thickened mitral valve
- Reduced Orifice area