Yesterday we saw three cardiovascular cases.
One of the doctors who attended for teaching had come to the classes for the first time, so we went through the method of examination of the cardiovascular system with him.
Again the stress was on correct method and the importance of doing one thing at a time.
The first patient was an elderly man who was breathless at rest and obese. Breathlessness suggested heart failure.
He had flaring of his alae nasi again in favour of heart failure.
His pulse rate was 90 beats per minute regular, normal volume, no abnormality in character.
JVP was elevated to the angle of the jaw, no dominant wave. This too added evidence to the fact that he was in heart failure.
There was a midline sternotomy scar, made us think of valve surgery. The apex beat was not displaced.
The first heart sound was normal. There was a click instead of the native second heart sound and there was an opening click just after the first heart sound.
No murmurs.
On examination of the back he had sacral oedema. This was initially missed by the candidate but when he was shown how one should run one’s finger down the spine, actively think of any spinal deformity and then look for sacral oedema, it was easily picked up
The lung bases were dull to percussion but there were no crepitations.
Diagnosis:
Aortic valve replacement, probably due to degenerative disease and congestive cardiac failure
The second patient we saw was the lady with mitral stenosis discussed yesterday with the medical students (see below)
The third patient was a middle-aged lady, lying comfortably in bed. She was obese.
No abnormality of the head
Pulse 80 beats per minute, regular good volume.
Neck normal.
No abnormality on inspection of the praecordium. Apex not displaced, normal character.
The first heart sound was of normal intensity. The second heart sound too was of normal intensity. There were no added sounds.
There was a blowing late systolic murmur heard at the apex. This murmur radiated to the axilla bit was also heard well at the base of the heart.
Diagnosis:
Mitral valve prolapse
The normal intensity of the first heart sound suggests that the valve is closing normally and hence not incompetent. The murmur beginning late in systole suggests that there is prolapse of the mitral valve. There was no mid-systolic click, which would have added more evidence in favour of mitral valve prolapse.
The ECHO confirmed prolapse of the posterior leaflet of the mitral valve.
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2 comments:
would you like to establish the exaggeration of the late systolic murmur by:
Making the lady stand and increase afterload by opening and closing the fists ! both of which should increase the intensity of the murmur
the common belief is that decrease in left ventricular cavity size increases the murmur and hastens the click (standing , decreased venous return)
squatting (increased ventricular filling, we were taught that it increases afterload) isometric handgrip (increases afterload) have the reverse effect
in practice they are not commonly performed but I accept your comment is perfectly valid
Please interact in this manner as it increases the value of this material
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