1. 250 CASES IN CLINICAL MEDICINE 2. Dedicated to The memory of
my paternal grandparents Bantwal Vaikunta and Sharada Baliga who
not only had the courage to actively participate in Indias freedom
movement but also to eat food with the so-called untouchables in
the 1920s when it was anathema to do so The memory of my maternal
grandparents Kochikar Sanjiv and Girija Pai who actively
participated in the underground movement during Indias pursuit for
freedom The memory of my father Ram Krishna Baliga who envisioned
the Electronic City in Bangalore, India, in the 1970s, making it a
modern-day global powerhouse My mother Shanthi Baliga who to this
day continues to pursue her lifetime social mission, which includes
emancipation of women and providing for indigent children My wife
Jayashree for her solid support over the last two decades My
siblings Narendra and Lathika for their help all along My children
Anoop and Neena 3. 250 CASES IN CLINICAL MEDICINE RAGAVENDRA R
BALIGA MD MBA DNB FRCP(Edin) FACP FACC Professor of Internal
Medicine Vice-Chief and Assistant Division Director, Division of
Cardiovascular Medicine, The Ohio State University Medical Center
Consultant Cardiologist, Stephen M. Ross Heart Hospital, Columbus,
Ohio Editor-in-Chief, Heart Failure Clinics of North America
Associate Editor, American College of Cardiology Cardiosource
Journal Scan FOURTH EDITION Edinburgh London New York Oxford
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5. v Preface: connecting-the-dots The current edition of the book
has been updated to reflect the new expec- tations of the Royal
College of Physicians and its examiners. The practice of clinical
medicine requires connecting-the-dots across pieces of infor-
mation; that is, it requires utilization of both verbatim memory
and gist memory (JAMA, 2009;302:13321333). Verbatim memory involves
mere recollection of facts (e.g. causes of pleural fluid) whereas
gist memory involves interpretation (e.g. that a very low pleural
fluid glucose in a patient with inflamed joints indicates that
rheumatoid arthritis may be the cause of pleural effusion).
Clinical examinations have been redesigned to reflect the
day-to-day practice of clinical medicine. Therefore, success in
clinical examinations requires development of both forms of memory.
Astute clinicians utilize such gist-based reasoning to arrive at
the right diagnosis, and their clinical reasoning is superior
because they are able to recognize the gist of clinical symptoms:
clinical examinations are designed to identify this competency.
This edition has been updated keeping in mind these new
expectations. More cases now have representative pictures to
enhance gist memory to help a prospective candidate to connect-the-
dots in the examination situation in a timely fashion; the text
provides material to improve verbatim memory. HOW TO USE THIS BOOK
Although this book is designed for the clinical examination it is
best uti- lized at least 6 months before the Part 1 MRCP written
examination and at least a year before the PACES clinical
examination. Simultaneous devel- opment of both gist and verbatim
memory requires a lot of practice and, therefore, this book is best
utilized at the bedside after seeing an index case. To improve gist
memory by only seeing patients (without using this book) is like
embarking on a trans-Atlantic flight without a flight plan, but
merely to read books without seeing adequate numbers of patients is
like a plane not taking off at all. Each candidate is encouraged
not only to see at least three to four representative patients of
each case but also to present each patient to a colleague who has
passed the examination or a consultant physician (i.e. each case
should have been presented by the candidate at least three to four
times before the examination); style matters as much as substance
and this requires practise, practise and more practise. This book
should continue to be useful for MBBS, PLAB, LRCP, MRCP (UK),
MRCPI, postgraduate clinical examinations in the US, Australia
(FRACP) and Canada (FCCP), and MD (New Zealand, Malaysia, Singa-
pore, India, Pakistan, Sri Lanka and Bangladesh). The current
organization of this book should also be appropriate for medical
students in the US taking the USMLE and for the American Board of
Internal Medicine Exam- ination (ABIM). Cases for examinations are
drawn from the same pool for both undergraduate and postgraduate
examinations, although in the latter the candidates performance has
to be faultless and he or she will be expected to know certain
aspects in greater detail. 6. Preface: connecting-the-dots vi
250CasesinClinicalMedicine Each case is discussed under a number of
headings. Instruction: this allows the candidate to know what sort
of instruction or command may be expected from an examiner. Salient
features: this section includes important features in each case
including aspects in history, physical signs, guidelines on how to
proceed when faced with these signs and what to tell the examiner,
in order to satisfy the examiner that the candidate is safe and
sound to be a competent clinician. Diagnosis: most candidates are
unable to present their diagnosis in a suc- cinct manner, although
they are able to elicit the clinical signs. This heading has been
included to help candidates to present their diagnosis in a crisp
and confident fashion. Questions: this section supplies the
questions (with answers) that a can- didate can expect in a given
case. These are also useful for the viva component of the
examination. Endnotes: many of the cases have endnotes giving
historical aspects rel- evant to that particular case, and some
have key review references. Although examiners will not deduct
marks for ignorance of things that have little relevance to patient
welfare, candidates who know the facts can expect a congratulatory
glow to pervade the examiner, so that the rest of the questions may
be softened accordingly. R R B Commissioning Editor: Pauline Graham
Development Editor: Helen Leng Copy Editor: Jane Ward Project
Managers: Jess Thompson and Andrew Riley Designer/Design Direction:
Kirsteen Wright Illustration Manager: Merlyn Harvey Illustrators:
Ethan Danielson and Richard Prime 7. vii I would like to thank
Pauline Graham, Commissioning Editor for inviting me to update this
book and putting up with my expectations and balance the budget
allocated to this book by her superiors, Helen Leng, Develop- ment
Editor at Elsevier, for her patience and gentle but relentless
prodding to meet deadlines of this project. I thank Jess Thompson
and Andrew Riley for doing an outstanding job of managing the
editing, proofing and print- ing stages. Finally I thank Geoffrey
Gatts, my administrative assistant for his help. Acknowledgements
8. This page intentionally left blank 9. ix The author would like
to thank those who have provided the illustrations for this
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Philadelphia, PA: Mosby, 2009. Fig. 72.1: Schllhammer M, von
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Schreiner O, Galle PR. Coexistence of Cullens and Grey Turners
signs in acute pancreatitis. Am J Med 2009;122:3334. Fig. 115.1:
Forbes A Misiewicz JJ, Compton CC. (eds) Atlas of clinical
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Hoffbrand AV, Pettite JE. Color atlas of clinical hematology, 3rd
edn. London: Mosby, 2000. Fig. 119.2: Hoffman R, Benz E, Shattil S,
Furie B, Cohen H. Hematology: basic principles and practice, 5th
edn. Philadelphia, PA: Churchill Liv- ingstone, 2008. Fig. 123.1:
Bhangu AA, Keighley MRB. Flesh and bones of surgery. Edin- burgh:
Elsevier, 2007. Fig. 126.1: His ED. The leukemias of mature
lymphocytes. Hematol/Oncol Clin North Am 2009;23:84371. Fig. 127.2:
Canoso JJ. Rheumatology in primary care, Philadelphia, PA:
Saunders, 1997. Fig. 128.1 Kelley WN Harris ED, Ruddy S, et al.
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PA: Saunders, 1997. Fig. 149.2: Charles C, Clements P, Furst DE.
Systemic sclerosis: hypothesis- driven treatment strategies. Lancet
2006;367:168391. Fig. 131.2 Grainger RG, Allison D. Grainger &
Allisons diagnostic radiol- ogy, a textbook of medical imaging, 4th
edn. Edinburgh: Churchill Liv- ingstone, 2001. Fig. 132.2, 238.1:
Roberts JR, Hedges JR. Clinical procedures in emergency medicine,
5th edn. Philadelphia, PA: Saunders, 2009. Fig. 134.1, 134.2:
Rogers LC, Bevilacqua NJ. The diagnosis of Charcot foot. Clin
Podiatr Med Surg 2008;25:4351. Fig. 136.1, 139.1: Kronenberg HM,
Melmed S, Polonsky KS, Larsen PR. Williams textbook of
endocrinology, 11th edn. Philadelphia, PA: Saun- ders, 2008. Fig.
137.1: Larsen PR, Kronenberg HM, Melmed S. Williams textbook of
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137.2: Kanski JJ. Systemic diseases and the eye: signs and
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JE, Benedict GW. Mosbys guide to physical examination, 5th edn.
Philadelphia, PA: Mosby, 2004. Fig. 140.1: Zimmermann MB, Jooste
PL, Pandav C. Iodine deficiency dis- orders. Lancet
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Aster J. Robbins and Cotran pathologic basis of disease, 8th
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Clin North Am 2008;52:12953. 13. xiii Contents Cardiovascular
system History and examination of the cardiovascular system 1 1
Mitral stenosis 5 2 Mitral regurgitation 12 3 Mixed mitral valve
disease 18 4 Aortic regurgitation 20 5 Aortic stenosis 27 6 Mixed
aortic valve lesion 34 7 Mixed mitral and aortic valve disease 36 8
Hypertension 38 9 Atrial fibrillation 43 10 Palpitations 50 11 Slow
pulse rate 53 12 Gallop rhythm 56 13 Angina pectoris 58 14 Acute
myocardial infarction 64 15 Jugular venous pulse 74 16 Congestive
cardiac failure 77 17 Infective endocarditis 80 18 Prosthetic heart
valves 85 19 Tricuspid regurgitation 89 20 Mitral valve prolapse 91
21 Ventricular septal defect 94 22 Atrial septal defect 98 23
Hypertrophic cardiomyopathy 103 24 Patent ductus arteriosus 108 25
Pulmonary stenosis 111 26 Dextrocardia 115 27 Coarctation of aorta
117 28 Eisenmenger syndrome 122 29 Fallots tetralogy 126 30 Absent
radial pulse 131 31 Constrictive pericarditis 135 32 Permanent
cardiac pacemaker/implantable cardioverter-defibrillator 138 33
Pericardial rub 142 34 Primary pulmonary hypertension 145 35
Ebsteins anomaly 151 Neurology History and examination of the
nervous system 155 36 Bilateral spastic paralysis (spastic
paraplegia) 165 37 Hemiplegia 169 14. Contents xiv
250CasesinClinicalMedicine 38 Ptosis and Horners syndrome 176 39
Argyll Robertson pupil 180 40 HolmesAdie syndrome 183 41 Homonymous
hemianopia 186 42 Bitemporal hemianopia 188 43 Central scotoma 189
44 Tunnel vision 190 45 Parkinsons disease 191 46 Cerebellar
syndrome 200 47 Jerky nystagmus 202 48 Speech 204 49 Expressive
dysphasia 207 50 Cerebellar dysarthria 210 51 Third cranial nerve
palsy 212 52 Sixth cranial nerve palsy 214 53 Seventh cranial nerve
palsy: lower motor neuron type 216 54 Tremors 221 55 Peripheral
neuropathy 225 56 CharcotMarieTooth disease (peroneal muscular
atrophy) 228 57 Dystrophia myotonica 231 58 Proximal myopathy 236
59 Deformity of a lower limb 237 60 Multiple sclerosis 241 61
Abnormal gait 249 62 Wasting of the small muscles of the hand 251
63 Dermatomyositis 253 64 Facioscapulohumeral dystrophy
(LandouzyDjrine syndrome) 256 65 Limb girdle dystrophy 259 66
Myasthenia gravis 261 67 Thomsens disease (myotonia congenita) 265
68 Friedreichs ataxia 267 69 Motor neuron disease 270 70
Neurofibromatosis 276 71 Syringomyelia 280 72 Subacute combined
degeneration of the spinal cord 284 73 Tabes dorsalis 287 74 Ulnar
nerve palsy 290 75 Lateral popliteal nerve palsy, L4, L5 (common
peroneal nerve palsy) 294 76 Carpal tunnel syndrome 296 77 Radial
nerve palsy 299 78 Chorea 302 79 Hemiballismus 305 80 Orofacial
dyskinesia 306 81 Internuclear ophthalmoplegia 307 82
Cerebellopontine angle tumour 310 83 Jugular foramen syndrome 313
84 Pseudobulbar palsy 316 15. Contents xv
250CasesinClinicalMedicine 85 Bulbar palsy 318 86 Wallenbergs
syndrome (lateral medullary syndrome) 319 87 Winging of the scapula
321 88 Becker muscular dystrophy 322 89 Tetraplegia 326 90
BrownSquard syndrome 329 91 Cauda equina syndrome 331 92 Torsion
dystonia (dystonia musculorum deformans) 332 93 Epilepsy 334 94
GuillainBarr syndrome 338 95 Multiple system atrophy 342 96
Neurological bladder 346 Respiratory system History and examination
of the chest 351 97 Pleural effusion 355 98 Pleural rub 361 99
Asthma 364 100 Chronic bronchitis 368 101 Bronchiectasis 377 102
Cor pulmonale 381 103 Consolidation 383 104 Bronchogenic carcinoma
387 105 Cystic fibrosis 391 106 Fibrosing alveolitis 396 107
Pulmonary fibrosis 401 108 Pneumothorax 403 109 Old tuberculosis
407 110 Pickwickian syndrome 410 111 Collapsed lung 412 Abdomen
History and examination of the abdomen 415 112 Hepatomegaly 418 113
Cirrhosis of the liver 420 114 Jaundice 424 115 Ascites 426 116
Haemochromatosis 430 117 Primary biliary cirrhosis 434 118 Wilsons
disease 437 119 Splenomegaly 440 120 Feltys syndrome 444 121
Polycystic kidneys 446 122 Transplanted kidney 452 123 Abdominal
aortic aneurysm 455 124 Unilateral palpable kidney 460 125
Abdominal masses 462 126 Chronic lymphocytic leukaemia 464 16.
Contents xvi 250CasesinClinicalMedicine Rheumatology General
guidelines for examination of joints 467 127 Rheumatoid hands 472
128 Ankylosing spondylitis 477 129 Psoriatic arthritis 481 130
Painful knee joint 483 131 Osteoarthrosis 485 132 Gout 488 133
EhlersDanlos syndrome 492 134 Charcots joint 496 135 Stills disease
499 Endocrinology Examination of the thyroid 503 136 Graves disease
506 137 Exophthalmos 511 138 Hypothyroidism 516 139 Pretibial
myxoedema 521 140 Multinodular goitre 524 141 Carpopedal spasm
(post-thyroidectomy hypoparathyroidism) 527 142 Acromegaly 530 143
Hypopituitarism (Simmonds disease) 534 144 Addisons disease 536 145
Cushing syndrome 538 146 Gynaecomastia 542 147 Carcinoid syndrome
544 148 Obesity 546 Dermatology 551 149 Scleroderma 552 150
Maculopapular rash 555 151 Purpura 556 152 Psoriasis 558 153
Bullous eruption 563 154 HenochSchnlein purpura 566 155 Ichthyosis
569 156 Hereditary haemorrhagic telangiectasia (RenduOslerWeber
disease) 572 157 Herpes labialis 575 158 Herpes zoster syndrome
(shingles) 578 159 Lichen planus 581 160 Vitiligo 584 161 Raynauds
phenomenon 587 162 Systemic lupus erythematosus 589 163 Phlebitis
migrans 595 164 Erythema multiforme 597 17. Contents xvii
250CasesinClinicalMedicine 165 Erythema ab igne 599 166 Hirsutism
602 167 Acanthosis nigricans 605 168 Lipoatrophy 608 169 Lupus
pernio 611 170 Xanthelasma 615 171 Necrobiosis lipoidica
diabeticorum 618 172 Radiotherapy marks 620 173 Tendon xanthomata
623 174 Eruptive xanthomata 625 175 Palmar xanthomata 627 176
Pseudoxanthoma elasticum 628 177 Rosacea 632 178 Dermatitis
herpetiformis 635 179 Hairy leukoplakia 637 180 Kaposis sarcoma 639
181 PeutzJeghers syndrome 643 182 Pyoderma gangrenosum 645 183
SturgeWeber syndrome (encephalotrigeminal angiomatosis) 648 184
Acne vulgaris 652 185 Alopecia areata 655 186 Atopic dermatitis
(eczema) 657 187 Venous ulcer 660 188 Arterial leg ulcer 663 189
Erythema nodosum 665 190 Fungal nail disease 667 191 Lichen simplex
chronicus (neurodermatitis) 671 192 Nail changes 673 193
Onycholysis 675 194 Malignant melanoma 677 195 Seborrhoeic
dermatitis 680 196 Molluscum contagiosum 682 197 Urticaria 683 198
Mycosis fungoides (cutaneous T-cell lymphoma) 685 199 Urticaria
pigmentosa 688 200 Tuberous sclerosis (Bournevilles or Pringles
disease) 690 The fundus Examination of the fundus 697 201 Diabetic
retinopathy 699 202 Hypertensive retinopathy 706 203 Papilloedema
711 204 Optic atrophy 714 205 Retinal vein thrombosis 717 206
Subhyaloid haemorrhage 720 207 Retinitis pigmentosa 723 208 Old
choroiditis 726 209 Cholesterol embolus in the fundus 728 18.
Contents xviii 250CasesinClinicalMedicine 210 Vitreous opacities
731 211 Myelinated nerve fibres 732 212 Retinal changes in AIDS 733
213 Retinal detachment 736 214 Age-related macular degeneration
(senile macular degeneration) 738 Miscellaneous Examination of the
foot 745 215 Diabetic foot 746 216 Swollen leg I: deep vein
thrombosis 750 217 Swollen leg II: cellulitis 754 218 Clubbing 756
219 Dupuytrens contracture 759 220 Cataracts 762 221 Anaemia 764
222 Lymphadenopathy 768 223 Crohns disease 773 224 Dysphagia 776
225 Diarrhoea 778 226 Marfans syndrome 780 227 Nephrotic syndrome
783 228 Uraemia 785 229 Pagets disease 790 230 Parotid enlargement
794 231 Superior vena caval obstruction 796 232 Glass eye 799 233
Turners syndrome 800 234 Yellow nail syndrome 803 235 Osteogenesis
imperfecta 804 236 Downs syndrome 806 237 Late congenital syphilis
809 238 Arteriovenous fistula 812 239 Carotid artery aneurysm 814
240 Retro-orbital tumour 816 241 Achondroplasia 817 242 Breast lump
819 243 Gingival hypertrophy 824 244 Haemophilia A 825 245
Klinefelters syndrome 827 246 Macroglossia 829 247 Osteoporosis of
the spine (dowagers hump) 831 248 Pressure sores (bedsores) 836 249
Sickle cell disease 838 250 Thrush 841 Index 845 19. Cardiovascular
system 1 History and examination of the cardiovascular system
HISTORY Chest pain: exertional, at rest (when angina present,
comment on the Canadian Cardiovascular Angina class, p. 59)
Shortness of breath: exertional, at rest (when dyspnoea is present,
comment on the New York Heart Association class, p. 3), paroxysmal
nocturnal dyspnoea Palpitations (p. 50) Dizziness, presyncope,
syncope Swelling of feet. EXAMINATION OF THE CARDIOVASCULAR SYSTEM
1. Introduce yourself: I am Dr/Mr/Ms [???] May I examine your
heart? 2. Ensure adequate exposure of the precordium: Would you
take your top off, please? However, be sensitive of the feelings of
female patients. 3. Get the patient to sit at 45 degrees: use
pillows to support the neck. 4. Inspection: comment on the patients
decubitus (whether he or she is comfortable at rest or obviously
short of breath); comment on malar flush (seen in mitral stenosis).
5. Examine the pulse: rate (count for 15s), rhythm, character,
volume; lift the arm to feel for the collapsing pulse. Feel the
other radial pulse simultaneously. 6. Comment on the scar at
antecubital fossa (cardiac catheterization scars). 7. Look at the
tongue for pallor, central cyanosis. 8. Look at the eye for pallor,
Argyll Robertson pupil. 9. Examine the jugular venous pulse:
comment on the waveform and height from the sternal angle. Check
the abdominojugular reflux. 10. Comment on any carotid pulsations
(Corrigans sign of aortic regurgitation). 11. Examine the
precordium: comment on surgical scars (midline ster- notomy scars;
thoracotomy scars for mitral valvotomy may be missed under the
female breast). 12. Feel the apex beat: position and character. 13.
Feel for left parasternal heave and thrills at the apex and on
either side of the sternum. 14. Listen to the heart, beginning from
the apex: take care to palpate the right carotid pulse
simultaneously so that the examiner notices that you are timing the
various cardiac events: Always comment on the first and second
heart sounds; mention any additional heart sounds (Fig. I.1);
listen to the heart murmurs and be prepared to draw what your hear.
If you do not hear the mid-diastolic murmur of mitral stenosis,
make sure you listen to the apex in the left lateral position with
the bell of the stethoscope. 20. History and examination of the
cardiovascular system 2 250CasesinClinicalMedicine If you hear a
murmur at the apex, ensure that you get the patient to breathe in
and out: the examiner will be observing whether or not you are
listening for the variation in intensity with respiration. If you
hear a pansystolic murmur, listen at the axilla (mitral regur-
gitant murmurs are conducted to the axilla). Note: Be prepared to
discuss approach of systolic and diastolic murmurs (see below). 15.
Using the diaphragm of your stethoscope listen at the apex, below
the sternum, along the left sternal edge, the second right
intercostal space and the neck (for ejection systolic murmur of
aortic stenosis, aortic sclerosis). Fig. I.1 Timing of the
different heart sounds and added sounds. Atrial or presystolic
gallop (S4) Split first heart sound Aortic or pulmonary systolic
ejection click (EC) Split second heart sound Opening snap of mitral
stenosis (OS) Third heart sound (S3) Midsystolic click (SC) S4 M1
A2 P2 S3 S1 S2 OS SC T1 EC A B C D E F G 21. Classifying severity
of heart failure 3 250CasesinClinicalMedicine 16. Request the
patient to sit forward and listen with the diaphragm along the left
sternal edge in the 3rd intercostal area with the patients breath
held in expiration for early diastolic murmur of aortic
regurgitation. 17. Tell the examiner that you would like to do the
following: Listen to lung bases for signs of cardiac failure Check
for sacral and leg oedema Examine the liver (tender liver of
cardiac failure), splenomegaly (endocarditis) Check blood pressure
(BP) Check the peripheral pulses and also check for radiofemoral
delay. ASSESSING MURMURS Systolic murmur What is the effect on the
murmur of inspiration? (a) Increases with inspiration (right
sided): Ejection or regurgitant? If ejection, is there an ejection
sound? If no ejection sound, is S2 fixed or not fixed? (b) No
increase with inspiration (left sided): Is it ejection, regurgitant
or uncertain? For each what is the effect of the Valsalva manoeuvre
or squatting? Diastolic mumur What is the effect on the murmur of
inspiration? (a) Increases with inspiration (right sided): Assess
quality of mumur and location Is there pulmonary regurgitation. (b)
No increase with inspiration (left sided): Assess quality of mumur
(high or low pitched) and location. CLASSIFYING SEVERITY OF HEART
FAILURE The severity of heart failure is classified by the New York
Heart Associa- tion (NYHA) classification, which grades symptoms
and gives estimated mortality. NYHA class Symptoms Estimated 1-year
mortality I Mild: no limitation of physical activity 510 II Mild to
moderate: slight limitation of physical activity, comfortable at
rest but dyspnoea and fatigue on ordinary physical activity 1530
III Moderate: marked limitation of physical activity, comfortable
at rest but dyspnoea and fatigue on less than ordinary physical
activity 1530 IV Severe: symptoms at rest 5060 Further reading
Bruns DLA: A general theory of the causes of murmurs in the
cardiovas- cular system, Am J Med 27:360, 1959. 22. History and
examination of the cardiovascular system 4
250CasesinClinicalMedicine Ren Theophile Hyacinthe Laennec invented
the stethoscope in 1816 and reported his early experience with
auscultation in a two-volume book published 3 years later: Laennec
RTH (1821) A Treatise on the Diseases of the Chest. London: T and G
Underwood (translated by and with a preface and notes by John
Forbes). British physician Sir John Forbes (17871861) is best
remembered for popularizing the stethoscope among English-speaking
doctors. Forbes was born in Banff in the northeast of Scotland. He
studied at Marischal College, Aberdeen, before he went to Edinburgh
where he received his medical education. Forbes translated Laennecs
monograph in English in 1821 and published his own book on the
subject in 1824 (Forbes J (1824) Original Cases with Dissections
and Observations Illustrating the Use of the Stethoscope and
Percussion in the Diagnosis of the Diseases of the Chest. London: T
and G Underwood). The latter included a brief biographical sketch
of the Austrian physician Leopald Auenbrugger and the first English
translation of his essay (which was in Latin) on percussion. It
also contained a summary of Parisian physician Victor Collins
recent manual on cardiac physical diagnosis. 23. 1Salient features
5 250CasesinClinicalMedicine 1 MITRAL STENOSIS INSTRUCTION This
patient developed shortness of breath and orthopnoea during preg-
nancy, please examine. This 55-year-old patient has atrial
fibrillation, please do the relevant clini- cal examination.
SALIENT FEATURES History Symptoms of left-sided heart failure:
exertional dyspnoea, orthopnoea, paroxysmal dyspnoea. Less frequent
symptoms: haemoptysis, hoarseness of voice, symptoms of right-sided
failure (these symptoms are somewhat more specific for mitral
stenosis). Obtain a history of rheumatic fever in childhood.
Examination Pulse is regular or irregularly irregular (from atrial
fibrillation). Jugular venous pressure (JVP) may be raised. Malar
flush. Tapping apex beat in the 5th intercostal space just medial
to midclavicu- lar line. Left parasternal heave (indicating right
ventricular enlargement). Loud first heart sound. Opening snap (OS;
often difficult to hear; a high-pitched sound that can vary from
0.04 to 0.10s after the second sound (S) and is heard best at the
apex with the patient in the lateral decubitus position). Rumbling,
low-pitched, mid-diastolic murmur, best heard in the left lateral
position on expiration. In sinus rhythm there may be presystolic
accentuation of the murmur. If you are not sure about the murmur,
tell the examiner that you want the patient to perform sit-ups or
hopping on one foot to increase the heart rate. This will increase
the flow across the mitral valve and the murmur is better heard.
Pulmonary component of second sound (P) is loud. Notes 1. Remember
the signs of pulmonary hypertension include loud P2, right
ventricular lift, elevated neck veins, ascites and oedema. This is
an ominous sign of the disease progression because pulmonary hyper-
tension increases the risk associated with surgery (Br Heart J
1975;37:748). 2. In patients with valvular lesions, a candidate
would be expected to comment on rhythm, the presence of heart
failure and signs of pulmo- nary hypertension. 3. In atrial septal
defect, large flow murmurs across the tricuspid valve can cause
mid-diastolic murmurs. The presence of wide, fixed splitting of
second sound, absence of loud first heart sound, and an opening
snap and incomplete right bundle branch block should indicate the
correct diagnosis. However, about 4% of the patients with atrial
septal 24. Mitral stenosis 6 250CasesinClinicalMedicine 1 defect
have mitral stenosis, a combination called Lutembacher syndrome.
DIAGNOSIS This patient has mitral stenosis (lesion), which is
almost always caused by rheumatic heart disease (aetiology), and
has atrial fibrillation, pulmonary hypertension and congestive
cardiac failure (functional status). QUESTIONS What is the
commonest cause of mitral stenosis? Rheumatic heart disease. What
is the pathology of mitral stenosis? The main features are leaflet
thickening, nodularity and commissural fusion, all of which result
in narrowing of the valve to the shape of a fish mouth. What is the
natural history of mitral stenosis? From the occurrence of
rheumatic fever to the onset of symptoms, there is a long latent
period of 20 to 40 years in Europe and North America. Moreover,
there is a further period of about 10 years before symptoms become
disabling. The 10-year survival of untreated patients is 50% to
60%, depending on symptoms at presentation: When the patient is
asymptomatic or minimally symptomatic the survival is >80% at 10
years with 60% of patients having no progres- sion of symptoms.
Once significant limiting symptoms occur, the 10-year survival rate
(is poor) 015%. When there is severe pulmonary hypertension, mean
survival drops to
