Mitral stenosis

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Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a low pitched “rumbling” middle and late diastolic murmur loudest in the mitral region, which increased on expiration and was accentuated in the left lateral position, which I believe is consistent with mitral stenosis.

 

I will now present my findings in full before commenting on severity, aetiology and differentials.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____ with a small pulse pressure.

 

On examination of the face, there was no scleral icterus, conjunctival pallor, xanthelasma, or malar flush. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave (prominent A for pulmonary HTN)

 

The carotid pulse was normal in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat was tapping apex beat in the fifth intercostal space mid-clavicular line. There was no diastolic thrill at the apex. There was/was not a palpable P2 or a left parasternal heave, which would suggest pulmonary hypertension.

 

On auscultation, as aforementioned, there was an early opening snap and a mid to late diastolic murmur loudest in the mitral region, which increased on expiration, and was accentuated in the left lateral position. There was presystolic accentuation (from atrial contraction if in sinus rhythm). There was/was not any change with dynamic Valsalva and isometric maneuvers.

 

There was a loud first heart sound, with physiological splitting, with no additional third or fourth heart sound.

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, Mr X presented with SOB, and my findings are consistent with mitral stenosis with/without associated atrial fibrillation.

 

In terms of severity:

• The presence of a small pulse pressure, a diastolic thrill, an early opening snap, the length of the murmur, and pulmonary hypertension findings suggest mild/moderate/severe.

• There was/was not evidence of decompensation.

• Length = if severe it will be an earlier or even continuous murmur. This early diastolic murmur will be descrescendo

 

In terms of aetiology:

• I could not ascertain the aetiology with certainty, although this may include rheumatic heart disease, or severe calcification.

• The presence of mixed valvular disease suggests rheumatic heart disease as a potential cause

 

Whilst my findings are consistent with mitral stenosis, other differentials would include:

• Aortic regurgitation, however, I would expect an early diastolic murmur with a more descrescendo character with greatest intensity at the lower left sternal edge

• Pulmonary regurgitation, however, it was not in greatest intensity in the expected area

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram

• Assessing for complications with an ECG to screen for AF, and a CXR to screen for pulmonary congestion

 

What are the aetiologies of MS?

• Rheumatic heart disease

• Degenerative/calcification

• Congenital

• Carcinoid

 

What are the indications for surgery?

• Don't have up to date answer to this - look this up 

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What are your investigation findings?

• ECG - P mitrale, AF, right axis deviation (if severe)

• CXR

  • MV calcification

  • Enlarged left atrium (double shadow, carinal splaying)

  • Signs of pulmonary hypertension (large central PA)

  • Signs of cardiac failure