A.S
Complaint (C/O)
Attack of loss of consciousness one week
ago.
Ø History Of Present
Illness (HPI)
-
The condition started 20 years
ago by exertional syncope not associated with convulsion or cyanosis.
one year later, the patient developed retrosternal constricting chest pain radiated to the left
shoulder, increased by exercise, relieved by rest and treatment lasted for 10
minutes. The patient sought medical advice, admitted to Shebin El-kom
University Hospital
-
The patient remained symptom
free till one week ago when he
redeveloped a similar attack of exertional syncope not associated with
convulsions or cyanosis.
-
No symptoms of pulmonary
congestion.
Ø Past history
-
There is past history of
rheumatic fever since he was 14 years old, manifested by fever and arthritis, investigated
by CBC, ESR and ECHO, treated by aspirin and the condition relieved and he was advised to take long acting
penicillin for life and it was recurrent
several times.
-
No DM no HPN.
-
No past history of operations
or drugs.
Ø Family history
-
No consanguinity
-
No common diseases
-
No similar condition
Ø General exam
-
Temperature : 37°
-
Blood pressure : 110/70
-
Pulse : regular
pulse ,75 /minute, average volume ,no special characters, vessel wall is not
felt ,equal on both sides with intact peripheral pulsations. Notice in some
cases of AS the pulse is too weak to be felt.
-
Average built.
-
No cyanosis, pallor
or jaundice.
-
No special decubitus (the
patient is lying free flat comfortable in bed).
-
No oedema L.L
-
No clubbing
-
Neck veins are
pulsating not congested.
Ø Local exam :
● Inspection and palpation
-
Left inframammary thoracotomy
scar of mitral valvotomy.
-
Normal shape of chest.
-
No dilated veins.
-
No pericardial bulge.
-
Regarding pulsations :
Apex: Regular apex, 75/min,
lies in left 5th space MCL, localized, heaving in character, with no thrill and
no rocking movement Otherwise, apart from weak epigastric pulsations
originating from aorta no other visible or palpable pulsations.
● By palpation only :
-
Thrill over
the 1st aortic area, propagated to the neck (In some cases, this thrill is not
present)
-
Pulsations the
same as above
-
Palpable sound : there
is no palpable 1st heart sound or diastolic shock
● Percussion :
Hepatic dullness in the Rt. 6th space MCL ,no dullness in the Rt.
parasternal area, both aortic and pulmonary areas are resonant, preserved waist
of the heart, no dullness outside the apex, lower end of the sternum is
impaired note with dull bare area.
● Auscultation
-
2nd sound muffled
-
Systolic harsh murmur ,maximum
intensity over the 1st aortic area
propagated to the neck and the apex, increased on setting leaning forward and
holding breath in full expiration ,it's organic of grade IV/VI with associated thrill ( the thrill may not be present and the
murmur of grade III/IV)
-
Ejection click may be
heard !!
Ø Investigation
-
ECG for
chamber enlargement and ischemia.
-
CXR for
chamber enlargement.
-
ECHO (investigation
of choice ): for anatomical functional aetiological diagnosis and for detection
of complication.
Ø Treatment
-
Medical
(prophylactic and symptomatic).
-
Interventional ballon
aortic valvoplasty.
-
Surgical (aortic
valve replacement).
Ø Diagnosis :
-
Rheumatic heart disease , in
the form of isolated aortic stenosis ,the patient is compensated and not
complicated
● NB :
-
Rheumatic from history
-
AS from history , exam (systolic
thrill over the 1st aortic area, data of auscultation )
-
Compensated from (absence of
symptoms and signs of pulmonary congestion ). Don’t forget signs of LVF :apical
gallop, pulsus alternans, bilateral basal crepitations)
-
Not Complicated
Note
You may find peripheral signs of aortic regurge with signs of aortic
stenosis …. this mean you are dealing with double aortic lesion.
Best of luck
B.H
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