G Kusuma
58
I am final year student taking part in active learning in solving case given to me in the following link
Cheif complaints
- Chest pain since 2 months
- Palpitation since 2 montha
- Dyspnea
- Bilateral pedal edema extending till ankle
- Decreased urine output
Chest pain
> towards left
> more in epigastric region
>non radiating
Is it cardiopulmonary or non cardiac causes lead too chest pain ???? Was my first question
For that major causes of chest pain should be aligned
Interpretation from above causes
Cardiac: acute caronary mainly MI
Troponin is negative so cant be MI
, pericarditis, myocarditis since this are sudden acute in onset can be ruled out and mainly no history of fever seen
Non cardiac causes no history is suggestive of non cardiac causes so i rule out
Probability of valvular disease is still a question which should be confirmed
It might also be anemia or thyroid dysfunction
Palpitations
What made the person to palpate ....????
What investigation done to patient suggestive or localise palpitation???
- What about pulse
Feeble , irregularly iregular
- Ecg??
Irregular rythm P wave absent indicating atrial
Right axisis deviation indicating enlarged heart
St elevation in v4 v5 aVR
Jvp was raised and showed prominent a wave
What is the correlation of atrial contraction abnormality & DYSPNEA , PEDAL EDEMA , DECREASED URINE OUT PUT ?????
So the pulmonary edema might be resulting in dyspnea
Orthopnea
Decreased urine out put might be due to decreased blood flow to kidney asa compensation of decreased activity of the heart which also explains pedal edema
Other investigation
On Auscultation,
Mitral area: Loud S1 heard
Tricuspid area: Loud S1 heard
Pulmonary area: Splitting of S2-loud P2 component
-On X-ray imaging: Cardiomegaly - Enlargement of Rt. Atrium, Rt. Ventricle, Lt. Ventricle
-In 2D echo, Mitral valves calcification and fish mouth appearance was seen
Provisional diagnosis : Mitral valve stenosis with heart failure
Treatment
If you have mild to moderate mitral valve stenosis with no symptoms, you might not need immediate treatment. Instead, your doctor will monitor the valve to see if your condition worsens.
Medications
No medications can correct a mitral valve defect. However, certain drugs can reduce symptoms by easing your heart's workload and regulating its rhythm.
Your doctor might prescribe one or more of the following medications:
Diuretics to reduce fluid accumulation in your lungs or elsewhere.
Blood thinners (anticoagulants) to help prevent blood clots. A daily aspirin may be included.
Beta blockers or calcium channel blockers to slow your heart rate and allow your heart to fill more effectively.
Anti-arrhythmics to treat atrial fibrillation or other rhythm disturbances associated with mitral valve stenosis.
Antibiotics to prevent a recurrence of rheumatic fever if that's what caused your mitral stenosis.
Procedures
You may need valve repair or replacement to treat mitral valve stenosis, which may include surgical and nonsurgical options.
Percutaneous balloon mitral valvuloplasty
In this procedure, also called balloon valvotomy, a doctor inserts a soft, thin tube (catheter) tipped with a balloon in an artery in your arm or groin and guides it to the narrowed valve. Once in position, the balloon is inflated to widen the valve, improving blood flow. The balloon is then deflated, and the catheter with balloon is removed.
For some people, balloon valvuloplasty can relieve the signs and symptoms of mitral valve stenosis. However, you may need additional procedures to treat the narrowed valve over time.
Not everyone with mitral valve stenosis is a candidate for balloon valvuloplasty. Talk to your doctor to decide whether it's an option for you.
Mitral valve surgery
Surgical options include:
Commissurotomy. If balloon valvuloplasty isn't an option, a cardiac surgeon might perform open-heart surgery to remove calcium deposits and other scar tissue to clear the valve passageway. Open commissurotomy requires that you be put on a heart-lung bypass machine during the surgery. You may need the procedure repeated if your mitral valve stenosis redevelops.
Mitral valve replacement. If the mitral valve can't be repaired, surgeons may perform mitral valve replacement. In mitral valve replacement, your surgeon removes the damaged valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve).
Biological tissue valves degenerate over time, and often eventually need to be replaced. People with mechanical valves will need to take blood-thinning medications for life to prevent blood clots. Your doctor will discuss with you the benefits and risks of each type of valve and discuss which valve may be appropriate for you.
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