o utline of p resentaion 2 to present a case of a 24f presenting with shortness of breath to present...

OUTLINE OF PRESENTAION

2

To present a case of a 24F presenting with shortness of breath

To present an approach to a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To present the pathophysiology and symptomatology of mitral stenosis

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities








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CASE PRESENTATION

R.F. 24 y/o Female

CHIEF COMPLAINT: Shortness of breath

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HISTORY OF PRESENT ILLNESS

ADMISSION5

REVIEW OF SYSTEMS

Poor appetite No headache/blurring of vision No cough/colds Occasional chest pain No abdominal pain/no vomiting No joint pains

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PAST MEDICAL HISTORY

No previous hospitalizations (+) episodes of sore throat and fever as a

child No hypertension No diabetes No surgeries

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FAMILY HISTORY

(-) Heart disease (-) Diabetes (-) Asthma/Allergies

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PERSONAL/SOCIAL HISTORY

Non-smoker Non-alcoholic beverage drinker

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PHYSICAL EXAMINATION FINDINGS

Conscious, coherent, ambulatory BP: 120/80 HR: 70 bpm RR: 20’s Warm moist skin ,no dermatoses

HEART: apex beat 7th LICS, MCL(+) accentuated S1(+) diastolic murmur

LUNGS: symmetric chest expansionno retractions(+) occasional wheeze

No cyanosis/edema10

MISSING DATA General Data

Address, occupation, civil status, religion HPI

Type of vitamins taken when consult was done Other possible associated signs and symptoms

ROS Qualify occasional chest pain

PE findings Specific RR Temp BMI JVP

Personal and Social History Type of diet, exercise Occupation (type, workload)

Environmental History Area of residence and associated living conditions

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SALIENT FEATURES

24 F BP: 120/80 RR: 20s (+) episodes of sore

throat

Progressive shortness of breath

Symmetrical chest expansion

(-) Retractions (+) Wheeze

Apex beat: 7th LICS, MCL

(+) Accentuated S1 (+) Diastolic

murmur

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DYSPNEA

a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity

derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses

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APPROACH TO A PATIENT WITH DYSPNEA

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CHEST PAIN

discomfort or pain anywhere along the front of your body between your neck and upper abdomen

Can be due to cardiopulmonary problems, chest wall problems, GI, psychological

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(+) EPISODES OF SORE THROAT

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CLINICAL IMPRESSION & DIFFERENTIALS

Salient features upon PE: Apex beat displacement Accentuated S1 Diastolic murmur Occasional wheezes

CV Disease Type of Murmur Heart Sounds Causes Pathophysiology Cardiac Enlargement

Mitral Stenosis

Low frequency diastolic rumble

S1 increased, S2 splitpalpable at left sternal border

rheumatic fever or cardiac infection

Narrowed valve restricts blood flow leading to forceful ejection into the venticle

LA enlargement

Aortic Stenosis

Midsystolic ejection murmur

S1 at apex, S2 soft or absent, S4 palpable

congenital bicuspid valves, rheumatic heart disease, atherosclerosis

Calcification of valve cusps restricts forward flow, forceful ejection from ventricle into systemic circulation

LV enlargement

Pulmonic Stenosis

Systolic murmur S1 followed by ejection click, S2 diminished, S4 present in RVH

Tricuspid Stenosis

Diastolic rumble accentuated early and late in diastole

S2 split during inspiration

rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myoxoma

Calcification of valve cusps restrict forward flow, forceful ejection into the ventricles

RV enlargement

CV Disease Type of Murmur

Heart Sounds Causes Pathophysiology Cardiac Enlargement

Mitral Regurgitation

Holocystolic, harsh blowing quality

S1 diminished rheumatic fever, myocardial infarction, myoma, rupture of tendinae

Valve incompetence allows backflow of blood from ventricle to atrium

LV enlargement

Mitral Valve prolapse

Late systolic murmur

variable mid systolic click

Valve is competent early in systole but prolapses into the atrium in later systole

LV enlargement

Aortic Regurgitation

Early diastolic, high pitch

S1 soft, S2 split rheumatic heart disease, endocarditis, aortic diseases

Valve incompetence allows backflow of blood from the aorta to ventricle

LV enlargement

Pulmonic Regurgitation

Difficult to distinguish from aortic regurgitation on PE

Difficult to distinguish from aortic regurgitation on PE

Secondary to pulmonary hypertension or bacterial endocarditis

Valve incompetence allows backflow of blood from the pulmonary artery to right ventricle

RV enlargement

Tricuspid Regurgitation

Holosystolic murmur

S3 and thrill over tricuspid

CLINICAL IMPRESSION (UPON PE)

Mitral Stenosis

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OUTLINE OF PRESENTAION To present a case of a 24F presenting with

shortness of breath To present an approach to a patient with

shortness of breath To present the differential diagnosis and

clinical impression of the patient To present the pathophysiology and

symptomatology of mitral stenosis To discuss the chest x-ray findings and

correlate it with the PE examination findings To discuss the roles of other imaging

modalities23

ETIOLOGY AND PATHOLOGY Rheumatic fever is the leading cause less common etiologies of obstruction to left

atrial outflow: congenital mitral valve stenosis mitral annular calcification with extension onto the

leaflets systemic lupus erythematosus rheumatoid arthritis left atrial myxoma infective endocarditis with large vegetations

pure or predominant MS occurs 40% of all patients with rheumatic heart disease and a history of rheumatic fever

lesser degrees of MS may accompany mitral regurgitation (MR) and aortic valve disease

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RHEUMATIC MS the valve leaflets are diffusely thickened by fibrous

tissue and/or calcific deposits mitral commissures fuse, the chordae tendineae fuse

and shorten, the valvular cusps become rigid, lead to narrowing at the apex of the funnel-shaped ("fish-mouth") valve

initial insult to the mitral valve is rheumatic, later changes may be a nonspecific process resulting from trauma to the valve caused by altered flow patterns due to the initial deformity

Calcification of the stenotic mitral valve immobilizes the leaflets and narrows the orifice further

Thrombus formation and arterial embolization may arise from the calcific valve itself, but in patients with atrial fibrillation (AF), thrombi arise more frequently from the dilated left atrium (LA), particularly the left atrial appendage

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PATHOPHYSIOLOGY hemodynamic hallmark of MS: blood flows from the LA

to the left ventricle (LV) is propelled by an abnormally elevated left atrioventricular pressure gradient

pulmonary venous and pulmonary arterial (PA) wedge pressures = pulmonary compliance = to exertional dyspnea

dyspnea are precipitated by clinical events that increase the rate of blood flow across the mitral orifice = LA pressure

the elevated LA and PA wedge pressures exhibit a prominent atrial contraction and a gradual pressure decline after mitral valve opening

In severe MS: pulmonary vascular resistance is significantly increased, the pulmonary arterial pressure (PAP) is elevated at rest and rises further during exercise, often causing secondary elevations of right ventricular (RV) end-diastolic pressure and volume

LV diastolic pressure and ejection fraction (EF) are normal

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PULMONARY HYPERTENSION passive backward transmission of the elevated LA

pressure pulmonary arteriolar constriction, triggered by LA and

pulmonary venous hypertension (reactive pulmonary hypertension)

interstitial edema in the walls of the small pulmonary vessels

organic obliterative changes in the pulmonary vascular bed

severe pulmonary hypertension results in RV enlargement, secondary tricuspid regurgitation (TR) and pulmonic regurgitation (PR), as well as right-sided heart failure

APEX BEAT DISPLACEMENT

Patient AB: 7th LICS, MCL Lateral and/or inferior displacement of the

apex beat usually indicates cardiomegaly. May also be displaced by other conditions:

Pleural or pulmonary diseases Deformities of the chest wall or the thoracic

vertebra

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(+) ACCENTUATED S1

Mitral valve snaps shut more vigorously, producing a louder S1 Blood velocity is increased-> anemia, fever,

hyperthyroidism, anxiety, and during exercise Mitral valve is stenotic

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(+) DIASTOLIC MURMUR

Early diastolic Begins with S2

Mid diastolic Begins at clear interval after S2

Late diastolic (presystolic)

Begins immediately before S1

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(+) DIASTOLIC MURMUR

Heard with bell at apex, patient in left lateral decubitus position

Findings on examination Low-frequency diastolic rumble, more intense in

early and late diastole, does not radiate; systole usually quiet; palpable thrill at apex in late diastole common; S1 increased and palpable at left sternal border

Description Narrowed valve restricts forward flow; forceful

ejection into the ventricle Often occurs with mitral regurgitation caused by

rheumatic heart fever or cardiac infection 31

LUNG FINDINGS

Occasional wheeze Musical respiratory sounds thaat may be

audible both to the patient and to others Suggests partial airway obstruction from

secretions, tissue inflammation, or a foreign body.

Wheezing is one of the manifestations of pulmonary congestion (cardiac asthma).

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CHEST PA CHEST LAT

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Patient’s PA CXR

Normal PA CXR

(-) blunting of the costophrenic angle(-) pulmonary congestion

(-) pulmonary infiltrates (-) bone deformities

(-) flattening of the R&L hemidiaphragm(-) tracheal deviation

Patient’s PA CXR

Normal PA CXR

(+) heart enlargement

Slight straightening of the L cardiac border

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Normal location of the apex: 5th ICS, MCL

Normal PA CXR

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The patient’s apex is located on the 7th ICS MCL

– DOWNWARD DISPLACEMENT OF THE APEX

Patient’s PA CXR

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Patient’s PA CXRNormal PA CXR

CARDIO-THORACIC RATIO

WHICH CHAMBER/S IS/ARE ENLARGED?

Squire’s Fundamentals of Radiology, 6th ed.

1 – R brachiocephalic vessels

2 – Ascending aorta and superimposed SVC

3 – R atrium

5 – L brachiocephalic vessels

6 – Aortic arch

7 – Pulmonary trunk

8 – L atrial appendage

9 – L ventricle

Normal LVE LAE LAE & LVE (in long-standing MS)

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Patient’s PA CXRNormal PA CXR

Prominent L atrial appendage

Left Atrial Enlargement

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Patient’s PA CXR

Normal PA CXR

Carina not appreciated (cannot be measured for widening)

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Patient’s PA CXR

Normal PA CXR

Double density not demonstrated along the R

cardiac border43

Patient’s PA CXR

Normal PA CXR

PULMONARY FINDINGS: CEPHALIZATION

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PULMONARY FINDINGS: CEPHALIZATION

Pruning of Pulmonary vessels

Pulmonary vessels

Pruning of Pulmonary vessels

Pulmonary vessels

Patient’s PA CXR

Normal PA CXR

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Normal PA CXR

Downward dipping of

the left heart

Patient’s PA CXR

POSSIBLE L VENTRICULAR ENLARGEMENT

Normal PA CXR

Prolonged LV outflow

tract

Patient’s PA CXR

POSSIBLE L VENTRICULAR ENLARGEMENT

POSSIBLE R VENTRICULAR ENLARGEMENT

Rounding of the cardiac apex

Patient’s PA CXR

Normal Lateral CXR

Patient’s Lateral CXR

Trachea

EsophagusTrachea

Esophagus

Heart

Heart

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Left atrial enlargement

Esophagus

Retrocardiac free space

Esophagus

Retrocardiac free space

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LV outflow tract

Left cardiac border

Left cardiac border

LV outflow tract

Possible Left venticular enlargement

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Possible Left venticular enlargement

Hoffman Rigler Sign

2 cm

> 1.8 cm

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Right ventricular enlargement

Retrosternal space

2/31/3

Retrosternal space

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LA enlargement LV enlargement RV enlargement 53

POSSIBLE CAUSES

Mitral StenosisMitral regurgitationMitral valve prolapseTricuspid stenosisPulmonic regurgitationAortic stenosisAortic regurgitationCor pulmonale

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ECHOCARDIOGRAM

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2D ECG: SIGNIFICANCE

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2D ECHOCARDIOGRAM IN MS

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SUMMARY

Case of a 24F presenting with shortness of breath

Approach to a patient with shortness of breath

Differential diagnosis and clinical impression of the patient

Pathophysiology and symptomatology of mitral stenosis

Chest x-ray findings and correlate it with the PE examination findings

Roles of other imaging modalities 63

o utline of p resentaion 2 to present a case of a 24f presenting with shortness of breath to present...

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