Abas, KristineAlfelor, RemelouAraneta, LoisBagacay, Julius**

30 year old male FilipinoGeneral manager of JollibeeCHIEF COMPLAINT: Difficulty of Breathing

**

HISTORY OF PRESENT ILLNESS**

SALIENT FEATURES(+) Easy fatigability(+) Shortness of breath when at work(+) Palpitations accompanied by chest pain occurring even at restProgression of symptomsNo relief with Seretide(-) Fever(-) Smoker(+) nonproductive cough for 3 weeks esp when supine(+) episodes of near syncope(+) swelling of both feet(+) maternal history of heart disease (died at 45yrs old)*

**

REVIEW OF SYSTEM(+) nonproductive cough for 3 weeks especially when supine(+) episode of near-syncope few weeks ago(+) swelling of both feet(-) fever, (-)headache/dizziness, (-) abdominal pain, (-) changes in bowel character, (-) dysuria, (-) joint pain

**

PHx: nonsmoker, no intake of alcoholic beverage, currently works as a manager in Jollibee

Past Medical Hx: (-) hypertension, diabetes, allergies(+) asthma recently diagnosed and maintained on Seretide BID

Family Hx:, (-) HPN, diabetes, asthma(+) heart disease mother, died at 45 years old**

PHYSICAL EXAMINATIONGeneral Survey: conscious, coherent, ambulatory, very anxiousVital Signs: BP=90/60, HR=102/min (irregularly irregular)RR= 24/min, Temp: 36.8oCWeight: 46 kg, Height: 155cm, BMI= 19.0HEENT: pink palpebral conjunctivae, no cervical lymphadenopathyicteric scleraeSkin:good skin turgor, no lesionsNeck: no carotid bruits, brisk upstroke of carotid pulse, JVP=5 cm at 30o**

PHYSICAL EXAMINATIONLungs: equal chest expansion, no retractions, equal tactile fremitus both lung fields, resonant to percussion on both lung fields(+) fine basilar crackles on both lung fieldsCardiac:(+) RV heave, no thrills, apex beat at the 5th ICS 2 cm lateral to the left midclavicular line, loud S1 at apex, prominent P2 at the base, (+) gr 3/6 middiastolic rumble at apexExtremities: (+) gr 1 bipedal edema, dorsalis pedis pulse (+2), no clubbing, no cyanosis**

Additional PE that should be done:Presence of oral ulcersMitral FaciesJoint tendernessSubcutaneous nodulesAbdominal examNeurologic exam**

**

Other PE findings to be done:Presence of oral ulcersMitral faciesJoint tendernessSubcutaneous nodulesAbdominal examNeurologic exam**

DIFFERENTIAL DIAGNOSISMitral Valve DiseaseMitral StenosisMitral RegurgitationAtrial MyxomaAsthmaChronic Obstructive Pulmonary Disease (COPD)PRIMARY WORKING IMPRESSION:MITRAL VALVE STENOSIS**

DIAGNOSTICS**

LABS CBC FBS: 80Hgb 12 Creatinine: 1.0Hct 0.48 Na 142, K 3.5, SGPT 40WBC 10 seg 55% Urinalysis: lympho 45% Spec grav 1.030plt 230,000 (-)sugar, WBC, RBC

Additional Diagnostics2D EchocardiographyHolter Monitoring

**

**

**

**

DIAGNOSISUnderlying Etiology: Rheumatic Fever Anatomical Abnormalities: Mitral Valve Stenosis3) Physiologic Disturbances: Right Congestive Heart Failure4) Functional Disability: NYHA Class IV**

Pathophysiology

Pathophysiology

PathogenesisAssociated signs and symptomsMitral Stenosis(+)3/6 middiastolic murmur at apex, Loud S1

LA fails to empty blood to LVLA enlarges(+)LA enlargement on radiographDecrease LV filling = decrease CO

(+)Easy fatigability, Dyspnea on exertion

Increase pressure in pulmonary veins

Pathophysiology

PathogenesisAssociated signs and symptomsLA failure causes pulmonary hypertension and edema(+)Paroxysmal nocturnal dyspnea, progressive dyspnea, fine bibasilar crackles on both lung fields, non productive cough, (+)prominent pulmo vasc Increase pressure in pulmonary arteriesRV needs to increase effort in pumping blood to pulmonary vessels (+)RV heave, (+)possible RV enlargement on chest X-ray causing displacement of apex beat to 2 cm lateral to left MCL 5th ICS, (+)Prominent P2 at baseRV contributes to pulmonary congestion and later on fails

Pathophysiology

PathogenesisAssociated Signs and SymptomsRA unable to pump blood to RV due to increase pressure in the RV. RA soon failsRight heart failure causes pooling of blood to the venous side of the circulation (+)grade 1 bipedal edema

**

MITRAL STENOSIS: ManagementGoals of Medical Treatment:

Prevention / Treatment of ComplicationsMonitorPrevention of recurrent infection

Pharmacologic approach:Symptom Control:Beta blockers, nondihydropyridine calcium channel blockers, or digoxin for rate control of AFCardioversion for new-onset AF and HFDiuretics for HF.

Natural HistoryWarfarin for AF or thromboembolismPCN for RF prophylaxis

Mitral valvotomy is indicated in symptomatic [New York Heart Association (NYHA) Functional Class IIIV]2 ways: PMBV and Surgical Valvotomy

Date of download: 8/26/2013Copyright The American College of Cardiology. All rights reserved.From: ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic SurgeonsJ Am Coll Cardiol. 2006;48(3):598-675. doi:10.1016/j.jacc.2006.05.030Management strategy for patients with mitral stenosis and mild symptoms. *The committee recognizes that there may be variability in the measurement of mitral valve area (MVA) and that the mean transmitral gradient, pulmonary artery wedge pressure (PAWP), and pulmonary artery systolic pressure (PASP) should also be taken into consideration. There is controversy as to whether patients with severe mitral stenosis (MVA less than 1.0 cm2) and severe pulmonary hypertension (PH; PASP greater than 60 mm Hg) should undergo percutaneous mitral balloon valvotomy (PMBV) or mitral valve replacement (MVR) to prevent right ventricular failure. CXR indicates chest X-ray; ECG, electrocardiogram; echo, echocardiography; LA, left atrial; MR, mitral regurgitation; MVG, mean mitral valve pressure gradient; NYHA, New York Heart Association; PAP, pulmonary artery pressure; 2D, 2-dimensional.

Figure Legend:

Date of download: 8/26/2013Copyright The American College of Cardiology. All rights reserved.From: ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic SurgeonsJ Am Coll Cardiol. 2006;48(3):598-675. doi:10.1016/j.jacc.2006.05.030Management strategy for patients with mitral stenosis and moderate to severe symptoms. *The writing committee recognizes that there may be variability in the measurement of mitral valve area (MVA) and that the mean transmitral gradient, pulmonary artery wedge pressure (PAWP), and pulmonary artery systolic pressure (PASP) should also be taken into consideration. It is controversial as to which patients with less favorable valve morphology should undergo percutaneous mitral balloon valvotomy (PMBV) rather than mitral valve surgery (see text). CXR, chest X-ray; ECG, electrocardiogram; echo, echocardiography; LA, left atrial; MR, mitral regurgitation; MVG, mean mitral valve pressure gradient; MVR, mitral valve replacement; NYHA, New York Heart Association; 2D, 2-dimensional.

Figure Legend:

**

**ACC/AHA PRACTICE GUIDELINESEXECUTIVE SUMMARYACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive SummaryA Report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines(Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease)

**ACC/AHA PRACTICE GUIDELINESEXECUTIVE SUMMARYACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive SummaryA Report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines(Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease)

Outlook (Prognosis)The outcome varies. The disorder may be mild, without symptoms, or may be more severe and eventually disabling. Complications may be severe or life threatening. Mitral stenosis is usually controllable with treatment and improved with valvuloplasty or surgery.Possible ComplicationsAtrial fibrillation and atrial flutterBlood clotsto the brain (stroke), intestines, kidneys, or other areasCongestive heart failurePulmonary edemaPulmonary hypertension

**

**

**

General Data: 30 year old Filipino male from MakatiChief Complaint: difficulty of breathing

*HPI: 2 months prior to consult, the patient started to note easy fatigability and shortness of breath when at work, forcing him to take frequent breaks. He also noted palpitations accompanied by chest pain occurring even at rest. One month prior to consult, he noted progression of symptoms, now occurring more frequently and with less activity. He also noted waking up from sleep due to not getting enough air. When he consulted his family doctor, he was given Seretide inhaler to be used twice a day. Symptoms persisted despite medications, prompting present consult.

SERETIDE = Fluticasone + Sameterol ( Not used for acute asthma symptoms) *ROS: (+) nonproductive cough for 3 weeks especially when supine, (-) fever, (-) headache/dizziness, (+) episode of near-syncope few weeks ago, (-) abdominal pain, (-) changes in bowel character, (-) dysuria, (+) swelling of both feet, (-) joint pain

(+) nonproductive cough for 3 weeks especially when supine = PAROXYS(+) episode of near-syncope few weeks ago(+) swelling of both feet*PHx: nonsmoker, no intake of alcoholic beverage, currently works as a manager in JollibeePast Medical Hx: (+) asthma recently diagnosed and maintained on Seretide BID, (-) hypertension, diabetes, allergies**** It is important to ask the patient if he had a history of scarlet fever or sore throat that was poorly treated before way back 5-10 years agoFamily Hx: (+) heart disease mother, died at 45 years old, (-) HPN, diabetes, asthma**** Ask the patient the specific cause of death of the patient, his mother dying early due to heart disease can be an indication that the patient might have a congenital heart disease such as

*Physical Exam:General Survey: conscious, coherent, ambulatory, very anxiousVital Signs: BP=90/60HR=102/min, irregularly irregularRR=24/minTemp: 36.8oCWeight: 46 kgHeight: 155cmHEENT: pink palpebral conjunctivae, icteric sclerae, no cervical lymphadenopathySkin: good skin turgor, no lesionsNeck: no carotid bruits, brisk upstroke of carotid pulse, JVP=5 cm at 30oVery anxious = caused by difficulty of breathing or not feeling well, agitationBP = hypotensive = HR = tachycardic, irregularly irregular (atrial fibrillation???) = compensation for low cardiac outputRR = tachypnic = compensation for low cardiac output BMI = healthy46/2.425 = 18.9 = healthy weight range for asians (asian diabetes initiative)Icteric sclerae = jaundiceJVP=5 cm at 30o = increased right atrial pressure/ central venous pressureIcteric sclerae = jaundice (liver damage)

*Lungs: equal chest expansion, no retractions, equal tactile fremitus both lung fields, resonant to percussion on both lung fields, (+) fine bibasilar crackles on both lungfieldsCardiac: (+) RV heave, no thrills, apex beat at the 5th ICS 2 cm lateral to the left midclavicular line, loud S1 at apex, prominent P2 at the base, (+) gr 3/6 middiastolic rumble at apexExtremities: (+) gr 1 bipedal edema, dorsalis pedis pulse (+2), no clubbing, no cyanosis

Fine basilar crackles = wet lungs, PULMONARY EDEMA(+) right ventricular heaves = increase AV impulseprominent P2 at the base = pulmonics component of second heart sound accentuated, pulmonary hypertensionGrade 3/6 Mid diastolic rumble (apex) = disproportion between valve orifice sizes and flow rate in mitral/tricuspid valves; duration is index of severity of valve obstructionGrade 1 Bipedal edema = Right Heart FailureLoud S1 (apex) = position of mitral leaflets (onset ventricular systole)*Subc nodules in severe carditis of RFMitral facies of MSNeuro exam and oral ulcers for SLE >>>SOAP BRAIN MD mnemonics

Duration of murmur = correlates to severity of MS S2 OS interval = varies inversely with severity of MS

**Cardiac FindingsUsually normal or slightly enlarged cardio-thoracic ratioStraightening of left heart borderConvexity of left heart border 2 to enlarged atrial appendage--only in rheumatic heart disease Small aortic knob from decreased cardiac outputDouble density of left atrial enlargementRarely, right atrial enlargement from tricuspid insufficiency

**The information given was not enough to diagnose the underlying etiology.. If it is based on statistics, the etiology would be Rheumatic Fever. The patients mother also had a heart disease and died early indicating that the patient might have this congenital predisposed to have rheumatic fever. Test should lse be done to prove that it is cause by rheumatic fever or disease. These test are the following: Antistreptolysin O Antibodies, C-Reactive Protien, Sedimentary Rate. Congenital Mitral stenosis can also be considered but the patient should manifest the symptoms on earlier age. **