Presentation of TMSS Medical college,Bogra, Bangladesh.

1. Welcome to Case
presentation

6. A PATIENT
WITH
SHORTNESS
OF BREATH
AND
PALPITATION

7. A.H.M SHAHNEWAZ (SHOUBHO)
MD.ASHIF NAWAS
MADHU KC
SUMAYA BINTE RAZZAK
ANCHORING BY
TOWHIDA TASNIM

8. Name: Mrs. Ruma
Age: 20 years
Sex: Female
Religion: Islam
Marital status: Married
Occupation: Housewife
Adress: Kahalu, Bogra.
Date of Admission: 05.03.2017
Date of Examination: 05.03.2017

9. 1. Shortness of breath for 10
days
2. Palpitation for same duration.

10. According to the statement of the patient,
she was reasonably well 10 days back.
Then she developed shortness of breath.
Initially it was increased with heavy
exertion and relieved by rest. This
shortness of breath increased day by day
and now even at rest. Patient wake up from
sleep 3 to 4 hours after going to bed.

11. She also feels discomfort on lying flat
and feels better in sitting position. The
shortness of breath was not associated
with episodic attack, cough, no diurnal
variation and not in allergic condition.
Also not associated with chest pain, fever
and hemoptysis. She also complaints of
palpitation which increased with exertion
and relieved by rest. This palpitation was
not associated with chest pain, syncopal
attack and increase frequency of
micturition.

12. She complaints of general weakness on
mild to moderate daily activities. She
gave no history of weakness of any part
of the body.
For this above complaints patient got
admitted in this hospital for better
management.

13. She gave no history of Rheumatic fever,
infective endocarditis or any other past
important contributory illness.

14. Patient previously one time
admitted in this hospital for same
complaints. But she cannot
mention the name of drugs. But
mention that drugs are associated
with increase frequency of
micturition and one drug she took
Friday off.

15. Her parents are alive. She has two
brothers, two sisters and one child.
All are alive and apparently healthy.

16. Socio-economic history:
Low socio-economic condition.
Her husband left her one year
back.

17. Personal history:
She is non smoker, non alcoholic.

18. Immunization history:
She was immunized according to
EPI schedule

19. General Examination:
 Appearance:Ill
Looking
 Decubitus: on choice
 Body build: average
 Co-operation:co-
operative
 Nutrition: Average
 Anaemia: absent
 Jaundice: absent
 Cyanosis: absent
 Clubbing: absent
 Oedema: absent
 Koilonychia: absent
 Lueconychia: absent
 Pigmentation:
normally pigmented

20. Continued:
• Skin eruption:
absent
• Body hair:
normally
distributed
• Deformities:
absent
• Lymph node: not
palpable
• Thyroid gland: not
enlarged
 JVP: not raised
 Pulse: 96 beats/
min
 BP: 90/60 mm of
Hg
 Respiration: 20
breaths/min
 Temperature:
normal
 Dehydration:
absent.

21. A. Cardiovascular system:
1. Arterial pulse:
a. Rate: 96 beats/ min
b. Rhythm: regular
c. Volume & character: normal
d. Symmetry: all peripheral pulses are
bilaterally symmetrically palpable.
e. Condition of the vessel wall: normal
f. Radio-femoral delay: absent

22. 2. Blood pressure: 90/60 mm of Hg
3. JVP: Not raised
4. Examination of precordium:
a)Inspection:
Size and shape: normal
Visible pulsation: apex beat visible in mitral
area. Epigastric pulsation present
Venous engorgement: absent
No scar mark, No deformity.

23. b) Palpation:
 Apex beat: left 5th
ICS, 1cm
medially from mid clavicular line
and taping in nature
 Thrill: absent
 Left parasternal heave: present
 Pulmonary component of second
heart sound: palpable.

24. c) Percussion:
d) Auscultation:
 1st
heart sound: loud in mitral area
 2ne heart sound: Pulmonary component of 2nd
heart
sound is loud in pulmonary area
 Murmur: there is a mid diastolic murmur in the mitral
area which is low pitch, localized, rough rumbling which is
best heard in left lateral position breath hold after
expiration with the bell of the stethoscope. Murmur grade
is 3/6.

25. Continued:
 opening snap and presystolic
accentuation: present.
• Another pansystolic murmur is
present in tricuspid area which is
best heard in breath hold after
inspiration. Murmur grade is 3/6.

26. B.RESPIRATORY
SYSTEM:
 Inspection:
 Shape of the chest: elliptical shaped
 Movement of the chest: symmetrical
on both side
 Intercostal indrawing:absent
 Subcostal recession: absent
 Use of accessory muscle: absent
 Scar mark: absent
 Any visible pulsation : absent

27. Palpation:
 Position of trachea: centrally placed
 Position of apex beat: LT 5th
ICS 9 cm
lateral from midline
 Chest expansion: symmetrical on both
side
 Chest expansability: 3 cm
 vocal femitus: equal on both sides
 Percussion note:resonant on both side.

28. Auscultation:
 Breath sound: vesicular
 Bilateral basal crepitation present
 Vocal resonance: equal on both side.

29. C. Alimentary system:
There is no ascities, no hepatomegaly.
D. Other systemic examination:
Reveals no abnormalities.

30. Mrs. Ruma, 20 years old female, married,
muslim, housewife hailing from Kahalu, Bogra
admitted in this hospital with the complaints of
shortness of breath for 10 days and palpitation
for same duration. Initially shortness of breath
was Newyork Heart Association (NYHA) class-
I. now it become NYHA class- IV. This
shortness of breath not associated with chest
pain, fever, cough, haemoptysis, episodic
attack, diurnal variation or allergic condition.

31. She also complaints of palpitation
which increased with exertion and
relieved by rest. Palpitation was not
associated with chest pain, syncopal
attack or increase frequency of
micturition.
She complaints of fatigability in daily
activities and no weakness or paresis
in any parts of body.

32. On general examination:
appearance ill looking, anaemia,
cyanosis, oedema, jaundice,
clubbing, koilonychia, leukonychia
absent. Pulse- 96 beats/ min, blood
pressure- 90/60 mm of Hg,
respiration: 20 breaths/ min.

33. On systemic examination:
Cardiovascular system:
Pulse 96 beats/ min, BP- 90/60 mm of Hg,
JVP- not raised
Examination of precordium- size & shape of
the chest normal, apex beat is visible in
mitral area which is in left 5th
ICS, 1cm
medially to midclavicular line and taping in
nature. Thrill- absent, left parasternal heave-
present, pulmonary component of 2nd
heart
sound is palpable.

34. Auscultation: 1st
heart sound is loud in
mitral area and pulmonary component of
2nd
heart sound is loud in pulmonary area.
There is a mid diastolic murmur in mitral
area which is low pitch, localized, rough,
rumbling best heard in left lateral position in
breath hold after expiration with bell of the
stethoscope murmur grade is 3/6.
Opening snap and presystolic accentuation
are present

35. Another pansystolic murmur is
present in tricuspid area which is best
heard in breath hold after inspiration.
Murmur grade is 3/6.
On respiratory system- bilateral basal
crepitation are present
Other systemic examination reveals
no abnormalities.

36. So my clinical diagnosis is-
Mitral stenosis and pulmonary hypertension
with tricuspid regurgitation with Pulmonary
oedema most probably rheumatic in origin.

37. 1. ASD & TR ē Pulmonary HTN
2. Left atrial myxoma & TR ē Pul. HTN
3. Left atrial ball valve thrombus & TR
ē Pul. HTN
4. Severe AR & TR ē Pul. HTN

38. INVESTIGATION
1. ECG:
• Sinus tachycardia
• P mitralae
• Right ventricular hypertrophy
• Right axis deviation
2. CXR P/A view:
• Upper lobe diversion
• Straightening of the left heart border and
fullness of pulmonary conus
• Double shadow in right border of the heart

40. CHEST X-RAY

42. 3. Echo- 2D:
• Thickening, fibrosis and calcification of
mitral leaflets
• Diastolic doming of Anterior Mitral Leaflet
(AML)
• Both commissure are fused.
• LA seems to be dilated.

44. Continued:
4. Echo- M mode:
• There is dilatation of left atrium (56mm)
• Reduced EF slope.
• Mitral valve area is 0.9 cm2
5. Echo- CD:
• Color flow mosaic passing from LA to
LV.

46. 6. Cardiac catheterization: (Not done)
• It is unnecessary unless there is
associated-
a. Suspected coronary artery disease
b. Previous valvotomy
c. Signs of mitral regurgitation
d. Signs of severe pulmonary HTN
e. Signs of other valve disease
f. When mitral valve is calcified in chest
radiographs
g. MV replacenment ( especially in elderly)

47. Final Diagnosis
So final diagnosis is-
Mitral stenosis and pulmonary
hypertension with tricuspid
regurgitation with Pulmonary oedema
most probably rheumatic in origin.

48. 1.Medical
2. Surgical Intervention

49. A. Non pharmacological:
 Avoid strenuous activity.
 Dietary- less salt intake.
B. Pharmacological:
 Rheumatic prophylaxis
(Phenoxymethyl penicillin)
 Diuretics
 Digoxin
 Anti- coagulant

50. Continued:
Anticoagulant is indicated in-
• MS ē AF
• MS ē previous thrombo-embolic
event
• MS ē LA thrombus
• MS ē LA dilatation ≥ 55 mm
• MS ē spontaneous Echo-contrast

51.  PTMC (percutaneous
transluminal mitral
commisurotomy)

52. Closed mitral valvotomy
 Open mitral valvotomy
Mitral valve replacement.

53. Indication of PTMC
1. PTMC is best applied to symptomatic patients
with moderate to severe MS & favorable mitral
valve morphology that is Pliable non calcified
valve without significant sub valvular disease.
2. High surgical risk
3. Bridge procedure to mitral valve surgery
4. Patient refusal to surgery
5. Shortened life span with co morbidities.

54. Indication for Mitral valve
Replacement
 1. Associated substantial/significant mitral
regurgitation.
 2. Valve is rigid & calcified.
 3. moderate to severe mitral Stenosis &
thrombus in the LA despite anti coagulant.
 4. Severely distorted valve by previous operation.
 5. If it is not possible to improve valve function
significantly .

55. Mitral Stenosis with
Pregnancy
 Women with MS often become
symptomatic during pregnancy because of
significant increase in plasma volume &
heart rate.

56. Common complication of MS
during Pregnancy
 1. Pulmonary edema
 2. Atrial tachy-arrhythmias
 3. Thrombo-embolic complications .
 4. Premature birth
 5. Intra uterine growth restriction.

57. MANAGEMENT OF MS IN
PREGNANCY
Whole duration of pregnancy must be supervised by
Cardiologist & Gynaecologist.
During 1st
Trimester (1st
12 wks)
 If symptomatic – HF,AF
Medical Treatment:
-Beta blocker
-Digoxin
-Diuretics (with caution)
-Antibiotics
Termination of pregnancy-
If symptoms are not adequately controlled despite optimum
medical treatment.

58. During 2nd
Trimester (13-28 wks)
If symptomatic
-Optimal medical treatment
-Emergency PTMC / CMC – if symptoms are not well
controlled despite medical treatment.
During 3rd
Trimester (29-40 wks)
-Hospital delivery with shortening of 2nd
stage of
delivery.
-Elective PTMC / CMC.

59. MANAGEMENT OF MS
BEFORE PREGNANCY
 At the beginning thoroughly examines the
patient.
 Investigation according to necessity
 Treatment according to severety
 If tight MS: PTMC or operation before
conception
 If Moderate MS: Continue pregnancy and
follow up along with gynaecologist
 If Mild Ms: Continue pregnancy without any
hazard.

60. LEFT ATRIAL MYXOMA