CVS 3
Description
The patient was an elderly lady lying comfortably in bed.
She was short and thin.
On examination of her head there was no abnormality. In
particular she was not pale and there was no malar flush.
On examination of her hands there was no abnormality. Her
pulse rate was 80 beats per minute; irregularly irregular in rhythm and the
volume of the pulse was normal. The brachial artery and pulse were normal.
The JVP was elevated to the level of the angle of the jaw
and there was a V wave. The trachea was in the midline. The carotids were
normal.
There was no abnormality of the praecordium, the apex was
displaced to the 6th left intercostal space, it was thrusting in
nature and there was a systolic thrill. There was left parasternal heave and
closure of the pulmonary valve was palpable. On auscultation, the heart rate was
80 beats per minute and irregular, the first heart sound was soft, the second
heart sound was loud and single, there was a pan systolic murmur that radiated
to the axilla and to the angle of the scapula.
There was no sacral oedema, the lung bases were not dull to
percussion and breath sounds were vesicular with no added sounds.
Analysis
♥
The patient was short and thin. This could indicate chronic
disease of childhood such as rheumatic heart disease. (See
ACES for PACES page 178)
ª
The patient has an irregularly irregular pulse. This makes it
likely that the patient has atrial fibrillation. Atrial fibrillation would make
the presence of mitral valve disease likely. Normal volume would make it likely
to be mitral regurgitation rather than mitral stenosis
(See ACES for PACES Page 193)
¨
An elevated JVP with a V wave would make it likely that the
patient has tricuspid regurgitation
(See ACES for
PACES Page 198)
§
The displaced apex suggests volume overload, especially as it is
thrusting in nature. With the pervious findings and the absence of a collapsing
pulse, this makes it most likely that the patient has mitral regurgitation
(See ACES for PACES Page 202)
♥
The systolic thrill suggests mitral regurgitation
(See ACES for PACES Page 203)
ª
Left parasternal heave would suggest right ventricular hypertrophy
or mitral regurgitation (See ACES for PACES Page 203)
¨
The palpable P2 makes it likely that the patient has
pulmonary hypertension (See ACES for PACES Page 203)
§
The apex rate, which is not much greater than the radial pulse
rate, would indicate that this patient’s atrial fibrillation is well controlled.
♥
The soft first heart sound is in keeping with mitral regurgitation
(See ACES for PACES Page 205)
ª
The loud single P2 is more evidence in favour of
pulmonary hypertension (See ACES for PACES Page
206,207)
¨
The pan systolic murmur at the apex radiating to the axilla and
the angle of the scapula is more evidence in favour of mitral regurgitation
(See ACES for PACES Page 211,213)
§
There are many causes of mitral regurgitation
(See ACES for PACES Page 215)
At this age the most likely causes are degenerative
valvular disease or rheumatic carditis
Diagnosis
♥
Mitral regurgitation
ª
Atrial fibrillation
¨
Pulmonary hypertension
§
Tricuspid regurgitation
♥
Aetiology probably rheumatic carditis or degenerative valvular
disease
Mitral Regurgitation
See KEYS to SUCCESS in Medicine120-122 page
