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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
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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:

LUNGS:





apex beat 7th LICS, MCL
(+) accentuated S1
(+) diastolic murmur
symmetric chest expansion
no retractions
(+) occasional wheeze
No cyanosis/edema
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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
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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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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

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APPROACH TO A PATIENT WITH DYSPNEA
Dyspnea
Pulmonary
Obstructive
Vascular lung
disease
Restrictive
Extrapulmonary
Extrapulmonary
restrictions
Cardiovascular
diseases
Other causes
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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
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
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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

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
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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

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
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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

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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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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
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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
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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
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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.
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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
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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