Model Case - Mitral Stenosis

Case Presentation – Mitral Stenosis

45 years old female patient XYZ housewife from (place) came with the chief complaint of

Dysnea since 2 months

Palpitations since 2 months

Chest pain since 1 month

History of present illness –

My patient was asymptomatic 2 months back when she started getting dysnea which was insidious in onset of NYHA grade II, increased on exertion and decreased on rest.

She had palpitations since 2 months, NYHA grade II which were aggravated with exertion and decreased with rest.

( Palpitations suggest atrial fibrillation,VPCs,MR,AR,TR etc)

She also had chest pain since 1 month which was dull aching diffuse type in nature and present over the left side of chest, not radiating, no any aggravating factor but decreased on rest.

(RV hypertrophy can cause chest pain )

There is no history of orthopnea,PND,fatigue,syncope,cough,haemoptysis,cough with expectoration( all these are asked for left heart failure), fever ( for infective endocarditis), joint pains ( for rheumatic heart disease), swelling over legs, abdominal pain( for right heart failure).

Past History –

Patient is a known case of rheumatic heart disease diagnosed 8 years back for complaints of joint pain and fever.She has undergone PTMC 6 years back and was on regular treatment Inj Penidure 12 LU every 21 days since then.

Family History –

No history of DM,HTN,any heart disease,stroke or asthma in the family.

Personal History –

Patient is a housewife with normal apetite, normal bowel bladder habits with no any known allergy.

Diagnosis from history –

Cardiac or respiratory system is involved – Cardiac involnement is suggested by dysnea while respiratory involvement is ruled out as there is no cough, no expectoration, no haemoptysis …

Left sided or right sided heart involvement – In this case left sided heart involvement might be present as right sided symptoms are not present like sweeling over legs, abdominal pain ….

Aortic or mitral valve involved – Dysnea usually occurs first in mitral, last in aortic lesions.

Regurgitation or stenotic lesion – Palpitations are present first in regurgitant lesions while dysnea first in stenotic lesions.In this case, both are present.

Physical Examination –

Patient’s height is _ cms

Weight is _  kgs

She is conscious,co-operative with normal built and normal stature.

Her Pulse rate is _ /min, irregularly irregular,low volume with normal character,normal condition of vessel wall with a apex pulse deficit of > 20 beats/min with all peripheral pulses palpable,no radiofemoral delay.

Blood pressure -110/80 mmHg in right arm supine position.

JVP –

Temperature –

No pallor,cyanosis,icterus,clubbing,edema.

Systemic Examination –

Inspection – Chest is bilaterally symmetrical.Apex impulse is seen in 5th intercostal space in the midclavicular line.No any dilated scars,sinuses seen. No any other pulsations seen.

Palpation – Apex beat is confirmed is in 5th intercostal space in the midclavicular line. It is tapping in nature, no thrill felt.

Palpable P2 is present in pulmonary area - 2^nd intercostal space just to the left of sternum – diastolic shock.

Percussion – Left heart border corresponds to the apex beat. Right heart border is retrosternal.Dullness is present in left 2nd intercostal space.

Auscultation –

S1 is loud in the apical area, P2 is loud in the pulmonary area.

A low pitched mid-diastolic murmur can be heard at the apex of grade 3/4with a opening snap with no presystolic accentuation and heard best in left lateral position with bell of stethoscope in expiration.

No any other murmur can be appreciated.

Respiratory System –

Inspection- Trachea is central, all quadrants moving equally



Palpation- Trachea is central,tactile vocal fremitus equal on both sides



Percussion- Resonant note all over lung fields, liver dullness 5th ICS, cardiac dullness felt



Auscultation- Normal vesicular breath sounds, air entry equal on both sides, vocal resonance equal on both sides, no added sounds like crepts or ronchi

Per Abdomen - Umbilicus normal in position, No scars sinuses seen ,No tenderness, no organomegaly, no abdominal distension .

CNS - No neurodeficit, all sensory motor functions normal, spine normal.

Provisional Diagnosis –

Rheumatic heart disease with mitral stenosis in atrial fibrillation,no evidence of infective endocarditis,not in failure, status post PTMC on treatment.