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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 modalities 2 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 modalities 3 CASE PRESENTATION R.F. 24 y/o Female CHIEF COMPLAINT: Shortness of breath 4 HISTORY OF PRESENT ILLNESS 1 month PTA 2 weeks PTA • Patient started having episodes of shortness of breath • No consult was done nor medications taken • Increasing shortness of breath • Difficulty climbing 2 flights of stairs • Consult: given vitamins • No improvement • Progressive shortness of breath when walking a short 1 day PTA distance ADMISSION 5 REVIEW OF SYSTEMS Poor appetite No headache/blurring of vision No cough/colds Occasional chest pain No abdominal pain/no vomiting No joint pains 6 PAST MEDICAL HISTORY No previous hospitalizations (+) episodes of sore throat and fever as a child No hypertension No diabetes No surgeries 7 FAMILY HISTORY (-) Heart disease (-) Diabetes (-) Asthma/Allergies 8 PERSONAL/SOCIAL HISTORY Non-smoker Non-alcoholic beverage drinker 9 PHYSICAL EXAMINATION FINDINGS Conscious, coherent, ambulatory BP: 120/80 HR: 70 bpm RR: 20’s Warm moist skin ,no dermatoses HEART: LUNGS: apex beat 7th LICS, MCL (+) accentuated S1 (+) diastolic murmur symmetric chest expansion no retractions (+) occasional wheeze No cyanosis/edema 10 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 PE findings Specific RR Temp BMI JVP Personal and Social History Qualify occasional chest pain Type of diet, exercise Occupation (type, workload) Environmental History Area of residence and associated living conditions 11 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 12 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 modalities 13 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 14 15 APPROACH TO A PATIENT WITH DYSPNEA Dyspnea Pulmonary Obstructive Vascular lung disease Restrictive Extrapulmonary Extrapulmonary restrictions Cardiovascular diseases Other causes 16 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 17 (+) EPISODES OF SORE THROAT infection with group A βhemolytic Streptococcus pyogenes Valvular damage (mitral valve) acute rheumatic fever rheumatic heart disease regurgitation leaflet thickening, scarring, calcification, and valvular stenosis 18 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 modalities 19 CV Disease Type of Murmur Heart Sounds Causes Pathophysiology Cardiac Enlargement Mitral Stenosis Low frequency diastolic rumble S1 increased, S2 split palpable at left sternal border rheumatic fever or cardiac infection Narrowed valve restricts LA blood flow leading to enlargement forceful ejection into the venticle CLINICAL IMPRESSION & DIFFERENTIALS SalientMidsystolic features upon S1 at apex,PE: S2 congenital ejection murmur soft or absent, bicuspid valves, Apex beat displacement S4 palpable rheumatic heart Accentuated S1 disease, atherosclerosis Diastolic murmur Pulmonic Systolic murmur S1 followed by Occasional wheezes Stenosis ejection click, Aortic Stenosis Calcification of valve cusps restricts forward flow, forceful ejection from ventricle into systemic circulation LV enlargement Calcification of valve cusps restrict forward flow, forceful ejection into the ventricles RV enlargement S2 diminished, S4 present in RVH Tricuspid Stenosis Diastolic rumble S2 split during accentuated inspiration early and late in diastole rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myoxoma CV Disease Type of Murmur Heart Sounds Mitral Regurgitation Holocystolic, harsh blowing quality S1 diminished Mitral Valve prolapse Late systolic murmur variable mid systolic click Aortic Regurgitation Early diastolic, high pitch S1 soft, S2 split Pulmonic Regurgitation Difficult to distinguish from aortic regurgitation on PE Difficult to distinguish from aortic regurgitation on PE Tricuspid Regurgitation Holosystolic murmur S3 and thrill over tricuspid Causes Pathophysiology Cardiac Enlargement rheumatic fever, myocardial infarction, myoma, rupture of tendinae Valve incompetence LV enlargement allows backflow of blood from ventricle to atrium Valve is competent early in systole but prolapses into the atrium in later systole LV enlargement rheumatic heart disease, endocarditis, aortic diseases Valve incompetence allows backflow of blood from the aorta to ventricle LV enlargement Secondary to pulmonary hypertension or bacterial endocarditis Valve incompetence allows backflow of blood from the pulmonary artery to right ventricle RV enlargement CLINICAL IMPRESSION (UPON PE) Mitral Stenosis 22 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 modalities 23 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 24 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 25 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 26 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 28 (+) 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 29 (+) DIASTOLIC MURMUR Early diastolic Begins with S2 Mid diastolic Begins at clear interval after S2 Late diastolic (presystolic) Begins immediately before S1 30 (+) 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). 32 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 modalities 33 CHEST PA CHEST LAT 34 Patient’s PA CXR Normal PA CXR Trachea (-) tracheal deviation (-) pulmonary congestion (-) pulmonary infiltrates (-) flattening of the R&L hemidiaphragm (-) blunting of the costophrenic angle (-) bone deformities Normal PA CXR Patient’s PA CXR (+) heart enlargement Slight straightening of the L cardiac border 36 Normal PA CXR Normal location of the apex: 5th ICS, MCL 37 Patient’s PA CXR The patient’s apex is located on the 7th ICS MCL – DOWNWARD DISPLACEMENT OF THE APEX 38 CARDIO-THORACIC RATIO Normal PA CXR Patient’s PA CXR WHICH CHAMBER/S IS/ARE ENLARGED? Normal LVE LAE & LVE (in long-standing MS) LAE 1 – R brachiocephalic vessels 5 – L brachiocephalic vessels 2 – Ascending aorta and superimposed SVC 6 – Aortic arch 3 – R atrium 7 – Pulmonary trunk 8 – L atrial appendage 40 9 – L ventricle Squire’s Fundamentals of Radiology, 6th ed. Normal PA CXR Left Atrial Enlargement Patient’s PA CXR Prominent L atrial appendage 41 Normal PA CXR Patient’s PA CXR Carina not appreciated (cannot be measured for widening) 42 Normal PA CXR Patient’s PA CXR Double density not demonstrated along the R cardiac border 43 PULMONARY FINDINGS: CEPHALIZATION Normal PA CXR Patient’s PA CXR 44 PULMONARY FINDINGS: CEPHALIZATION Normal PA CXR Pulmonary vessels Pulmonary vessels Patient’s PA CXR Pruning of Pulmonary vessels Pruning of Pulmonary vessels 45 POSSIBLE L VENTRICULAR ENLARGEMENT Normal PA CXR Patient’s PA CXR Downward dipping of the left heart POSSIBLE L VENTRICULAR ENLARGEMENT Normal PA CXR Patient’s PA CXR Prolonged LV outflow tract POSSIBLE R VENTRICULAR ENLARGEMENT Normal PA CXR Patient’s PA CXR Rounding of the cardiac apex Normal Lateral CXR Patient’s Lateral CXR Trachea Trachea Esophagus Esophagus Heart Heart 48 Left atrial enlargement Esophagus Retrocardiac free space Esophagus Retrocardiac free space 49 Possible Left venticular enlargement LV outflow tract LV outflow tract Left cardiac border Left cardiac border 50 Possible Left venticular enlargement Hoffman Rigler Sign > 1.8 cm 2 cm 51 Right ventricular enlargement Retrosternal space Retrosternal space 1/3 2/3 52 LA enlargement LV enlargement RV enlargement 53 POSSIBLE CAUSES Mitral Stenosis Mitral regurgitation Mitral valve prolapse Tricuspid stenosis Pulmonic regurgitation Aortic stenosis Aortic regurgitation Cor pulmonale 54 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 modalities 55 ECHOCARDIOGRAM Most specific and sensitive method of diagnosing and quantifying the severity of mitral stenosis Graphic outline of the heart's movement . Two- dimensional (2-D) Echo is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart’s valves. 56 2D ECG: SIGNIFICANCE Assess the heart’s function Determine the presence of disease of the heart muscle, valves and pericardium, heart tumors, and congenital heart disease Evaluate the effectiveness of medical or surgical treatments Follow the progress of valve disease 57 2D ECHOCARDIOGRAM IN MS 58 2D ECHOCARDIOGRAM IN MS 59 2D ECHOCARDIOGRAM IN MS 60 2D ECHOCARDIOGRAM IN MS 61 2D ECHOCARDIOGRAM IN MS 62 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