52/M with valvular heart disease
50 year old male patient who is a farmer by occupation presented with complaints of
1- shortness of breath since 4 years
2- palpitations since 4 years .
Patient says he had chest pain 5 years back - diffuse ,squeezing and severe for 1 day -for which he visited a doctor and was said to have MI ?
Patient experienced severe shortness of breath 4 years back -at 12 am - sudden in onset ,severe and lasted for half hr to one hour ,he woke up and walked for few minutes and took rest .In the mrng patient went to hospital and was said to have cardiac disease ?
Later on he was put on medications and was on regular follow up .
Shortness of breath gradually progressed over 4 years -
Since 5 months patient is experiencing shortness of breath - on exertion ( farming ,on lifting heavy weights,walking for long distance ,climbing stairs) . patient work has been gradually declined over 5 months ,as he says he becomes dyspneic on doing heavy work .
That progressed to NYHA 4- assosciated with orthopnea ,PND , palpitations ,pedal edema,dry cough on lying down ,since 1 week .
No chest pain ,no giddiness .
No history of wheeze ,chest tightness .
no decreased urine output .
Ex smoker stopped since 4 years
And ex alcoholic - stopped 15 years back
Non DM ,Non HTN
On examination -
Pallor +
Mild icterus +
Clubbing -
Pedal edema+
Tachypneic +
Pulse - regular ,bounding , normal rhythm.,water hammer pulse +
Carotid - forceful +
Femoral - pistol shot sound heard
Bp- 120/50 mmHg ( wide pulse pressure )
Jvp - not raised
Cardiovascular examination -
On inspection -
Apex impulse visible in 6th ICs lateral to midclavicular line
No other precordial pulsations
No scars ,no sinuses
On palpation -
Apex impulse - felt at 6th ics ,lateral to midclavicular line ,2 cm away from mid clavicular line
Diffuse - LV type of apex
Pulsations at left parasternal region - no heave ,no lift
On auscultation -
Mitral area- s1 and s 2 heard
Tricuspid - S1 and S2 heard
Aortic - ejection systolic murmur .
Erbs point - left 3 ICS - diastolic murmur, intensityof murmur increased with isometric hand grip exercise.
Pulmonary -s2 split
Findings -
Dilated LV - cardiomegaly
With AR
Ecg : st depression -2,3,avf ,LVH +
Echo - severe eccentric AR ,with dilated LA,LV ,RA . Moderate MR .Global hypokinesia of LV .
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