58/F with shortness of breath
A 58 year old woman presented with the complaints of
Chief complaints: Shortness of breath with exertion since 1 year and at rest since 15 days
Cough intermittently since 4 months
Swelling of both lower limbs on and off since 2 months
Swelling of right lower limb since 10 days
History of present illness: the patient had complaint of shortness of breath since 1 year which was present with farm work started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest. Associated with increase during sleeping position and relieved during sitting or standing position.
Complaint of cough with expectoration intermittently, associated with worsening of chest pain, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, not foul smelling, no plugs, no frank blood.
Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides.
Not associated with chest pain, dizziness, loss of consciousness, abnormal sensations of heart beat.
Not associated with fever, loss of weight.
Associated with increased frequency of urination since 4 months
Past history: No history of similar complaints before 1 year. History of hospitalisation for 3 times in the past one year. Episodes of hospitalisation associated with worsening of shortness of breath, pedal edema and cough. Each time the patient’s attenders gave history of on and off medication intake.
No history of diabetes, hypertension, bronchial asthma, tuberculosis, jaundice.
No known drug allergies.
Family history: no history of similar complaints in the family. No history of sudden cardiac death in the family.
General physical examination: The patient appears conscious, cooperative, dyspnoea at rest present.
Pulse- rate 86 beats per min
Rhythm- regular, volume- low volume, equal pulses on both sides and in all peripheral areas, no radio radial delay, no radio femoral delay.
Blood pressure- 120/60mm Hg
Jugular venous pressure- engorged vein, pulsation, the patient has hepatojugular reflex
Respiratory rate - 24 cycles per minute
Spo2 - 96% on room air
Pallor- present, no icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema- present, bilateral pitting type, extending till ankles.
Cardiovascular examination:
Inspection:
No deformity or bulge in the precordium, apical impulse seen in fifth intercoastal space 1cm lateral to the midclavicular line, no diffuse pulsations over precordium, no superficial engorged veins. No scars or sinuses over the skin.
Pulsations seen on the right parasternal region and in the epigastrium.
No prominent pulsations in the aortic, suprasternal area, supraclavicular area, no visible carotid pulsation, no visible pulsations on the back.
No kyphosis, scoliosis, drooping of shoulder, winging of scapula.
Palpation:
Apex beat present in the fifth inter coastal space, left sided, 1cm lateral to the midclavicular line over 2 inter coastal spaces. Parasternal heave present on the left parasternal region, obliterated on pressure.
Palpable second heart sound in the pulmonary area, not associated with palpable thrill in the pulmonary area.
No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.
Percussion- right border of heart- dull ness on percussion seen till 2.5 cms lateral to the sternal border. Other borders not well localised.
Auscultation:
cardiac rate- about 87 beats per minute
Regular in rhythm
Mitral area- soft s1 heard, associated with diastolic murmur mid to late low pitched, no presystolic accentutation, more heard on the left lateral position. No radiation of the murmur heard.
Difficult to appreciate when the patient initially came to the hospital but better audible after initial management.
Pulmonary area- loud p2 heard, no murmur heard, no added sounds
Aortic area- s2 with normal split heard, no murmurs or added sounds heard
Tricuspid area- no murmurs or added sounds heard
Provisional diagnosis- based on the above history and examination the most probable diagnosis is moderate to severe mitral stenosis with frequent acute exacerbations of heart failure.
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