Needs immediate operation. Atrial fibrillation is rare. Common in South-East Asia. Haemoptysis in MS : explanation : The possible mechanisms are — 1. Pulmonary apoplexy — Due to rupture of thin-walled, dilated bronchial veins or pulmonary veins frank haemoptysis resulting from sudden rise in LA pressure. Winter bronchitis chronic bronchitis — Blood-streaked mucoid sputum. Acute pulmonary oedema — Profuse, pinkish, frothy sputum is produced due to rupture of capillaries into the alveoli.
Pulmonary infarction — Frank haemoptysis. Overdose of anticoagulant therapy rare — Often required for embolic manifestation. Pulmonary haemosiderosis — Rare. What is damped MS? Development of pulmonary hypertension diminishes the cardiac output throttle effect and results in temporary symptom-free period period of illusion. Often the mid-diastolic murmur is not audible and thus known as silent MS. What is intermittent claudication? This is a cramp-like pain, tightness and numbness due to ischaemia felt commonly in calves, thighs or buttocks on walking a certain distance, and characteristically relieved by taking rest.
The common causes are, 1. Coarctation of aorta. Lumbar canal stenosis patient often stoops forward during walking to reduce symptoms. If he continues to walk, paraesthesia in feet and even foot drop may develop. Palpation of peripheral pulses in legs, i. Common risk factors are diabetes, smoking, hypertension and hypercholesterolaemia.
Carey-Coombs murmur — Soft mid-diastolic murmur of active rheumatic valvulitis, localised to the apex. The murmur varies in intensity from day to day and usually disappears after the acute attack. There is absence of loud S,, opening snap and diastolic thrill.
Oedema of the matral valve cusps produce obstruction and gives rise to diastolic murmur. Increased flow through the normal mitral valve also occurs in severe MI. There is absence of diastolic thrill, opening snap and presystolic accentuation but S3 may be present. Tricuspid stenosis — Mid-diastolic murmur with presystolic accentuation which is loudest at lower left sternal edge.
Murmur increases at the height of inspiration. Features of RVH are never present. Ball valve thrombus — The thrombus usually floats in the left atrium and obstructs the mitral orifice in diastole. Echocardiography is essential for final diagnosis. Conducted murmur of AI — Early diastolic, soft blowing; no thrill, no opening snap. Peripheral signs of AI are present. Echocardiography and cardiac catheterisation are diagnostic. Describe the classical attack of paroxysmal nocturnal dyspnoea PND : It is the sudden and dramatic development of acute dyspnoea occuring in the early hours of night, i.
The patient is awakened from sleep with a feeling of apprehension, intense suffocation and choking sensation. He sits upright gasping in the bed with the legs hanging by the side of the bed to reduce left atrial pressure by gravitational pooling or rushes to an open window in the hope that cool fresh air will relieve him.
The cough becomes productive with profuse, watery, pinkish and frothy sputum due to acute pulmonary oedema collection of fluid within the alveoli. Acute pulmonary oedema is the severe form of cardiac asthma due to marked increase in pulmonary capillary pressure leading to alveolar oedema. Clinical examination at the time of an attack of PND reveals : a Severe dyspnoea and orthopnoea; tachypnoea associated with air hunger and recruitment of accessory muscles.
PND is a symptom of decompensation of the left heart. Why dyspnoea occurs in MS? Protective mechanisms to prevent pulmonary oedema in MS : As the disease progresses to chronic mitral stenosis, there is development of : 1. High pulmonary vascular resistance pulmonary hypertension , 2. Capillary-alveolar-interstitial barrier, and 3.
Broncho-pulmonary venous shunts. Thus, it is clear that a recent onset MS patient may die of LAF acute pulmonary oedema and an old or chronic patient dies of RVF from pulmonary hypertension.
An old case of MS usually does not suffer from PND because of the development of protective mechanisms mentioned above.
The causes of non-cardiogenic type are— 1. Diffuse pulmonary infections viral, bacterial, fungal, pneumocystis jiroveci. Inhalation of toxins and irritants phosgene, chlorine, high concentration of Severe sepsis, gram negative septicaemia, shock, major trauma, uraemia.
Miscellaneous — Cardio-pulmonary bypass, major blood transfusion reaction, anaphylaxis bee, wasp, snake venom, crab , major burns, head injury, SLE, DIC, lymphangitis carcinomatosa.
Remember, pneumonia exudate is not pulmonary oedema transudate. Why the dyspnoea is usually nocturnal in MS? Probable theories are : 1. Venous return increases in recumbency. Mobilisation of oedema fluid from extravascular to intravascular compartment on lying. Adrenergic drive is reduced during sleep. Heart rate increases during rapid eye movement REM sleep. Reduction of vital capacity in supine position.
Elevation of left atrial pressure and fall in Pa02 during sleep. Complications of MS : 1. Acute left atrial failure and acute pulmonary oedema. Pulmonary hypertension. Atrial fibrillation AF , atrial flutter, ventricular or atrial premature beats. Infective endocarditis — Very rare more common in milder form of MS than in severe form ; endocarditis is common in 'regurgitation' than in 'stenosis'.
Recurrent broncho-pulmonary infections. Jaundice, cardiac cirrhosis. Sudden death may be caused by ball valve thrombus where the LA outlet is blocked by large pedunculated thrombus.
How do you like to investigate a case of MS? Oesophagus is pushed or curved backward sickling of oesophagus by the enlarged LA. C Chest X-ray lateral view —Obliteration of retrosternal space in left lateral view with slight increase in transverse diameter of heart PA view indicates RVH. H Doppler study — To know the functional status, speed and direction of blood flow in the heart chambers; to record pressure gradient across mitral valve.
Rationality of nervous system examination in MS i. Hemiplegia or monoplegia may occur in a patient with MS commonly with atrial fibrillation. Sydenham's chorea. Fundoscopy — Roth spot, hypertensive retinopathy. Rationality of respiratory system examination in MS i. Respiration tachypnoea, orthopnoea. Hydrothorax from CCF. Crepitations at lung bases due to left-sided heart failure. Rationality of G. Liver — Soft and tender liver with mild enlargement due to CCF.
Spleen — In the presence of SBE, spleen may be palpable. Ascites may develop from CCF. Mesenteric embolism. Rationality of skeletal system examination in cardiac disorders : 1. Kyphoscoliosis shifting of apex beat, deformity of precordium. Polydactyly or syndactyly congenital heart disease. Rheumatoid arthritis or ankylosing spondylitis MI or AI ; rhumatic arthritis carditis.
Important points in general survey in CVS : 1. Decubitus - May be propped-up; orthopnoea. Nutrition - Cardiac cachexia in severe chronic heart failure. Anaemia - Present in SBE remember, anaemia can aggravate all heart diseases.
Cyanosis - Cyanotic congenital heart diseases, acute pulmonary oedema. BP - Must be seen in all patients: of immense value in diagnosis. Respiration - Tachypnoea, hyperventilation. Temperature - Elevated in SBE, tuberculous pericarditis.
Oedema - CCF, constrictive pericarditis, pericardial effusion, tricuspid value disease. Neck vein - Reflects central venous pressure; found in RVF.
Thyroid - One should search for thyrotoxic features in all CVS disorders. Jaundice - Rare; due to congestive hepatomegaly from CCF, or cardiac cirrhosis. Skeletal - Kyphoscoliosis, cubitus valgus, polydactyly. The different modalities of treatment are : a Drugs medical treatment.
Open valvotomy needs open heart surgery with cardio-pulmonary by-pass. Indications of valvotomy : 1. Progressive symptomatic deterioration inspite of medical treatment. MS with complications as mentioned earlier e. Asymptomatic patients with a single attack of thromboembolic manifestation.
MS with pregnancy where previous pregnancy was symptomatic. Contraindications of closed valvotomy : 1. MS with significant MI. Extremely tight stenosis. MS with left atrial thrombus. Mitral valve distorted by previous operation 3. Valvular calcification. Presence of active rheumatic carditis. Actually, these are indications for open valvotomy. Loud S, and OS persist after mitral valve prosthesis.
Criteria for mitral valvuloplasty : 1. Significant symptomatic MS. Pure MS may have trivial MI. Left atrium is free of clots. Valve and sub-valvular apparatus are free of calcification.
Treatment done in MS with Ml: Mitral valve replacement prosthesis. Mechanical prosthesis like Starr-Edwards valve or Bjork- Shiley valve, or porcine bioprosthesis may be used.
Prosthesis is done in grossly damaged valve and sub- valvular structures, and in presence of MI. Artificial valves may work for more than 20 years. Medical treatment in MS : 1. Treatment of CCF by restriction of physical activity, salt-restricted diet, diuretics and digoxin available as 0.
Secondary prevention of acute rheumatic fever is done. Anticoagulation in the presence of atrial fibrillation or big left atrial clot to reduce the risk of systemic embolism. Mitral Incompetence Treatment of atrial fibrillation with digoxin, 3-blockers or rate-limiting calcium channel blockers singly or in combination.
Management of complications like haemoptysis, acute pulmonary oedema are done accordingly. Of these, MS is the commonest lesion. The principles of management are, 1. Schedule treatment of MS. Note : functional degradation e. Increased bed rest. Adequate nutrition and correction of anaemia.
Therapeutic abortion—in selected cases e. Mitral valvotomy—in symptomatic tight MS, in midtrimester. Ideally all other cases should go Into labour with scrupulous monitoring and not allowing the patient to strain in 2nd stage of labour. Caesarean section may be performed where indicated. Patients are advised to restrict the number of children to one or two.
Metallic mitral valve prosthesis in MS—auscultatory findings : 1. A metallic sound is audible in mitral area which coincides with S. Normal S2. A metallic opening snap. Hancock porcine valve. MI or AS. Case 2 Mitral Incompetence. This is a case of organic mitral incompetence regurgitation of rheumatic origin with features of congestive cardiac failure and pulmonary hypertension, and the patient is in sinus rhythm at present. Build up the summary. The symptoms are almost similar to that of MS.
Symptomatology consists of exertional dyspnoea, orthopnoea, PND, fatigue, recurrent respiratory tract infections, palpitation, oedema feet due to CCF or features of SBE fever, embolic episodes etc. Palpitation is due to. Why it is a case of mitral incompetence MI? A Symptoms from the history : a Exertional dyspnoea, and b Palpitation for last 6 months.
B Signs : a Decubitus - Propped-up. The murmur is radiated towards the left axilla and inferior angle of left scapula hallmark of diagnosis ii Pulmonary area - Ejection systolic murmur different from pansystolic murmur at apex with loud P2. Features of LVH : Apex goes down and outwards.
Features of RVH : 1. Apex goes outwards. Left parasternal heave. Epigastric pulsation. Triple rhythm with sinus tachycardia is known as gallop rhythm — so called because of its resemblance with the cadence produced by galloping of horses. So, presence of gallop rhythm indicates heart failure. Fine crepitations at lung bases i. Pulsus altemans. Remember, pulmonary oedema is a feature of left-sided heart failure. Quadruple gallop — Four distinct heart sounds due to audibility of S3 and S4 separately, and 2.
Summation gallop — The extra sound is produced as a result of superimposition of S3 on S4 i. Engorged and pulsatile neck veins. Mildly enlarged, soft, tender liver. Dependent bipedal oedema pitting. Cardiac cachexia due to T tumour necrosis factor, T basal metabolic rate, anorexia, nausea, vomiting is not uncommon. What is apex beat? When the same cardiac pulsation is seen, it is called apical impulse.
If the apical impulse is not visible in supine position of the patient best visible from the right side of the patient by a tangential view , the patient is turned to left lateral position when the apical impulse may be visible somewhere near the left anterior axillary line.
Causes of non-visibility of apical impulse are same as causes of non-palpable apex see below. What is the significance of apex beat? It is an important parameter by which one can assess the enlargement of heart in the absence of push-pull effect of lung and the activity of myocardium.
How to localise the apex? The patient should lie flat or supine. Place your whole flat of right palm over the precordium always stand on the right side of the patient. Try to localise the definite thrust not necessarily the maximum with outstretched fingers.
If a definite thrust is palpable, confirm it by pulp of index or middle finger, and locate it by counting the ribs; look, how far it is from the left midclavicular line inside or outside. If the apex beat is not palpable in dorsal decubitus position, ask the patient to sit and lean forward.
Again try to locate it. If the apex is not palpable even in sitting position, place your right palm over the right side of the chest to detect the presence of dextrocardia or dextroversion. In palpating apex, why the finger is lifted in systole when the ventricle is contracting?
This is due to the complex rotatory movement of the heart in systole vortex like movement , one manifestation of which is the forward movement of apex the rotatory movement is due to the complex spiral arrangement of ventricular muscles.
Apex lying behind a rib. Pericardial effusion. Obesity or thick chest wall. Pendular breast in elderly female. Deformity of the chest gross kyphoscoliosis 4. Emphysema COPD. Thickened pleura left. Pleural effusion left. Heart failure. Pneumothorax left Heart may be somewhere else dextrocardia. Constrictive pericarditis. Describe different characters of the apex beat : The normal apex beat is early systolic outward thrust located at a point not more than cm in diameter.
The different types are : 1. As there is no obstruction to the blood pumped from the left ventricle, the apex remains ill sustained. The palpating finger is not lifted and the S: is felt as distinct palpable shock. In LV type the apex goes downwards and outwards as well as there is a larger impulse usually more than a paisa coin , and the impulse is maximal at the apex; if there is a left parasternal impulse, it is asynchronous with the apex beat.
Whereas in RV type, the apex goes outwards as well as there is production of left parasternal heave, and both are synchronous; in RV type, the cardiac impulse is maximal over the lower left sternal border. Remember, trachea is moved to the right side too. A Symptoms— 1. Breathlessness often severe; exertional. Syncope due to low fixed stroke volume. Easy fatiguability. Chest pain angina pectoris. Cough; haemoptysis. B Signs— 1. Pulse — Low volume.
Neck veins — a-wave is prominent. Central cyanosis—in right-to-left shunt, lung diseases COPD, interstitial lung disease. Among these features, the ejection systolic murmur with palpable as well as audible loud P2 are commonly found. RVH is usually present in a case of pulmonary hypertension of some duration.
Causes of pulmonary hypertension : Pulmonary hypertension is basically of two types : Primary pulmonary hypertension No. Vasoconstrictive hypoxic — Chronic cor pulmonale. Obstructive — Pulmonary thromboembolism acute cor pulmonale. Obliterative — SLE, systemic sclerosis, polyarteritis nodosa. Neurohumoral or idiopathic — Primary pulmonary hypertension common in females in 3rd and 4th decades. Miscellaneous — Sleep apnoea, Pickwickian syndrome, drugs like aminorex fumarate.
Grade II : No limitation under resting condition but symptoms appear on ordinary activity. Grade III : Limitation of activities on mild exertion or less than ordinary physical activity. Grade IV : Limitation of activities at rest, restricting the person to bed or chair. This is actually a classification of cardiac disability. Dyspnoea due to cardiovascular diseases should always be quantified by this classification.
Aetiology of MI: 1. Rheumatic commonest. IHD, myocarditis, cardiomyopathy or acute rheumatic carditis. Mitral valve prolapse syndrome MVPS.
Dysfunction of papillary muscle or chordae tendineae due to IHD i. Acute myocardial infarction due to rupture of papillary muscle. Traumatic — During mitral valvotomy. Infective endocarditis.
Dilated cardiomyopathy. Causes of acute MI:. Infective endocarditis rupture of valve cusps or chordae tendineae. Trauma in the chest. Bedside clinics in Medicine Part — 1 has 99 ratings and 0 reviews. Mohamed Bedsdie rated it liked it Sep 26, Jennifer rated it liked it Dec 29, Papa Kwesi rated it liked it Aug 05, This is the only book available which gives actual picture of bedside medicine. Dr Praveen rated it liked it Dec 21, Just a moment while we sign you in to your Goodreads account.
N may your tribe increase! Want to Read Currently Reading Read. Thanks for telling us about the problem. Lists with This Book. Meitei rated meedicine really liked it Aug 22, That u bestow a such a nice material for understanding a huge subject medicine, which made very easy for both clinical examination as well as theory exam n best supplement for pg entrance exam, thanks a lot.
But opting out of some of these cookies may have an effect on your browsing experience. Necessary cookies are absolutely essential for the website to function properly.
This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information. This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Privacy Overview This website uses cookies to improve your experience while you navigate through the website. Privacy Overview.
These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may have an effect on your browsing experience. Necessary cookies are absolutely essential for the website to function properly. This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies.
It is mandatory to procure user consent prior to running these cookies on your website. Skip to content. This website uses cookies to improve your experience.
0コメント