Download MBBS Case based scenario

Case based scenario

HISTORY

Chief complaints:

• Breathlessness since 2 weeks
• Palpitations
• Central chest discomfort

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History of presenting illness:

• exacerbation of breathlessness since two weeks
• Insidious in onset
• Progressively increased to occur on minimal exertion.
• He has also had episodes of awakening from sleep due to breathlessness
• He has noticed palpitations which aggravates on walking and is associated with throbbing sensations.

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• central chest discomfort on walking which is relieved on rest
• No history of cough, fever, loss of consciousness or swelling of feet or body.

Past history:

• recurrent episodes of joint pains in his adolescence
• associated with fever
• Untreated

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• Since 4 years, he has noticed dyspnoea on heavy exertion.
• He had stopped manual labour 2 years ago but was able to carry on his daily routine activities.
• Since the past 4 months, he was not able to walk more than a kilometre without shortness of breath.

Provisional diagnosis:

Most likely a case of valvular heart disease due to rheumatic origin involving mitral or aortic valve.

EXAMINATION

General physical examination

• Patient is conscious, oriented to time place and person

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• No pallor, icterus, cyanosis, clubbing, Lymphadenopathy or pedal edema.

Vitals:

• Pulse: Rate- 80/min, regular rhythm, high volume, collapsing
• JVP: normal
• Blood pressure: 160/20 mmHg, right arm in supine position.

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CVS examination:

• Apex : is in left 6th ICS, anterior axillary line, hyperdynamic.
• No thrill.
• Auscultation:
• Aortic area- high pitched, blowing, early diastolic murmur of grade 3 radiating to the apex.
• Ejection systolic murmur grade 2 also heard.

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• Other areas- normal sounds. R/S – normal. Abdomen- normal. CNS- Normal.

• R/S examination- normal.
• Abdomen- normal.
• CNS- Normal.

Differential Diagnosis

• Thyrotoxicosis

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• Aortic regurgitation
• Severe anemia
• Thiamine deficiency
• Sympathetic overdrive
• left heart failure

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• Mitral stenosis
• Mitral regurgitation.

INVESTIGATIONS

1. General investigations

   Complete blood count, DLC

   ESR, CRP

   Thyroid function tests

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   Urinary thiamine excretion, blood thiamine levels

   VDRL( for syphillitic aortitis)

   ASO titres

   Anti DNAse B

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2. investigation to rule out structural and functional heart defects.

   Echocardiography- to diagnose the valvular dysfunction

   Chest Xray

   ECG

   Cardiac catheterization.

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Diagnosis

• Chronic decompensated aortic regurgitation mostly Secondary to Rheumatic heart disease.

Management

• Asymptomatic patients with preserved ejection fraction are managed conservatively.
• Asymptomatic patients with reduced ejection fraction are managed surgically with aortic valve replacement.
• Symptomatic patients are managed with Aortic valve replacement.
• Management also depends on LV end ststolic and end diastolic diameter. (ESD> 50mm, EDD>65mm) are indication for aortic valve replacement.

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• Patient undergoing any cardiac surgery is also considered for aortic valve replacement.

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