M.S with T.R

M.S with T.R

Complaint (C/O)

Shortness of breath four months duration.

Ø  History Of Present Illness (HPI)

-          The condition started 10 years ago by gradual onset and progressive course of dyspnea. The patient experienced exertional dyspnea on less than ordinary effort, on climbing the 1^st floor not associated with orthopnea or PND. this dyspnea was associated with gradual onset, progressive course rapid irregular palpitation increased with exertion The patient sought medical advice, investigated by chest X-ray, ECG and ECHO diagnosed as tight mitral stenosis and treated by mitral valve replacement.

-          The patient was quite well, after operation, till 4 months ago when  he redeveloped again exertional dyspnea on less than ordinary effort associated with orthopnea, the patient used to sleep on three pillows  and PND, after one or two hours of sleep the patient usually  wakes up  with dyspnea ,cough and wheeze then after 15 minutes the condition usually relieves. This dyspnea is  associated with gradual onset, progressive course rapid irregular palpitation increased with exertion. Two months later, the patient experienced dyspepsia, dull aching pain in the right upper abdomen associated  with bilateral pitting painless lower limb edema extending to thigh level and also  gradual onset, progressive course of generalized abdominal distension.

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

● overview :

-          Temperature : 37^°

-          Blood pressure 110/70

-          Pulse : markedly irregular pulse, 75/minute, variable volume, pulsus deficit >10, vessel wall is not felt, equal on both sides with intact peripheral pulsations.

-          Orthopnea.

-          Average built, no pallor no jaundice, no cyanosis.

● Head & neck :

-          Congested pulsating neck veins extending to lobule of the ear, congestion decreased by inspiration with +ve hepato-jugular reflux. There is systolic expansion with absent a wave.

-          No malar flush.

● Extremities :

-          Bilateral pitting lower limb edema extending to mid thigh level, not tender.

Ø  Local exam :

● Inspection and palpation

-          Barrel  shaped chest "just association in our case".

-          Median sternotomy scar of valve replacement surgery.

-          Pericordial  bulge.

-          No dilated veins.

-          Regarding pulsations :

1. Apex: markedly irregular apex ,90/min, lies in left 5^th space outside MCL, diffuse, slappy in character, with no thrill and no rocking movement.
2. Pulmonary pulsation detected by palpation by tips of fingers.
3. Left parasternal pulsation detected by palpation by base of the hand, increased by chest deflation.
4. Epigastric pulsation detected by both inspection and palpation by tips of fingers increased by deep inspiration.
5. There is hepatic pulsation detected by bimanual palpation of the liver.

● By palpation only :

-          Pulsations the same as above.

-          Palpable sound : there is palpable 1st heart sound (slappy apex) but no diastolic shock "may be present in such cases, in our case may be masked by hyperinflation".

-          No thrill either on apex, left parasternal area or on base.

● Percussion :

Hepatic dullness in the Rt. 5^th space MCL, there is  dullness in the Rt. parasternal area, Aortic area is resonant while there is 3 finger dullness in  pulmonary area, obliterated waist of the heart (4 finger dullness in left 3^rd space, normally just 2 finger dullness), no dullness outside the apex, lower end of the sternum is stony dull with dull bare area.

● Auscultation

1- Over the apex

-          1st sound accentuated.

-          Diastolic rumbling murmur, localized over the apex, increased on lying in the left lateral position, it's organic, grade III/VI with no thrill.

-          OS may be heard !!

● NB : In AF : Variable 1^st  heart sound with no presystolic accentuation of the murmur.

2- Over the pulmonary area

2nd sound accentuated

Ejection systolic murmur of relative pulmonary stenosis (systolic, localized, soft, no thrill, grade III/IV, increased with setting, leaning forward).

3- Over the tricuspid area

Pan-systolic murmur of functional tricuspid Regurge (systolic, localized, soft, no thrill, grade III/IV, increased with inspiration "carvallo's sign").

Ø  Examination of other systems :

In this  case, you should search for other signs of systemic congestion other than edema and neck veins like ascites and enlarged tender liver  as a part of abdominal examination in such case.

Ø  Diagnosis :

Rheumatic heart disease , in the form of mitral restenosis with functional tricuspid regurge, the patient is decompensated and complicated by AF.

Or  

Rheumatic heart disease, in the form of mitral restenosis, the patient is decompensated and complicated by AF and functional tricuspid regurge.

● NB

-          Rheumatic  from history.

-          MS from history, exam (irregular pulse, slappy apex, auscultation, investigation).

-          TR from history, general signs of systemic congestion, signs of right ventricular enlargement, auscultation  and investigation ).

-          Decompensated from (symptoms and signs of systemic congestion).

-          Complicated by AF (irregular pulse with marked irregularity and pulsus deficit >10).