BEDSIDE CLINICS 9TH EDITION

Mitral Stenosis 9
2. Structural abnormality—Stenosis, regurgitation.
3. Aetiologieal — Rheumatic, congenital.
4. Complications — Pulmonaiy hypertension, CCF, subacute bacterial endocarditis (SBE) etc.
5. Rhythm — Sinus rhythm or dysrrhythmia (e.g., irregularly irregular rhythm due to atrial
fibrillation).
Some clinicians prefer to add NYHA classification in the provisional diagnosis (see page 24).
Why it is a case of mitral stenosis ?
It is a case of mitral stenosis because of the following :
(A) Symptoms (from the history) :
a) Breathlessness or effort intolerance for last 10 months.
b) Cough with haemoptysis from time to time for 1 month.
c) Attacks of paroxysmal nocturnal dyspnoea since last 2 weeks.
d) Past H/O rheumatic fever (tell about the symptoms).
(B) Signs :
a) Pulse - 78/minute, LOW VOLUME, REGULAR, no radio-radial or radio-femoral delay, all the
peripheral pulses are palpable, no abnormality in the arterial wall or no special character.
b) BP - Low (or normal).
c) Apex beat - Normal in position and tapping in character. There is presence of diastolic thrill,
best palpable in left lateral position and at the height of expiration. S, is palpable.
d) Auscultation (of the mitral area) :
S, - Short, sharp and accentuated (loud and snapping Sj — a very important clinical clue).
S 2 - Normal.
Opening snap — Audible, just after S 2 .
Murmur - Describe the classical murmur (as described in summary).
Other areas - No murmur.
* ADD FEATURES OF PULMONARY HYPERTENSION. IF PRESENT.
** Auscultatory cadence of murmur and heart sounds of MS are as follows: ffout (presystolic murmur
ending in loud Sj) — ta (S 2 ) — ta (opening snap) — rrrou (mid-diastolic murmur).
*** ‘Usually’ the apical impulse in an established MS is diffuse and formed by right ventricle. There is a
diastolic thrill at apex, best palpable at left lateral position. There is sustained left parasternal heave as
a result of RVH from pulmonary hypertension.
If no past H/O rheumatic fever present :
Rheumatic fever is the commonest aetiology of MS and it is true in other valvular heart diseases.
60% of the MS patients do not give definite H/O rheumatic fever, still one should consider rheumatic
fever as the probable aetiology. In that case it is better to say in P/D as ‘a case of MS probably of
rheumatic origin’.
Importance of past and family history in CVS :
Past history
Family history
1. Rheumatic fever 1. Hypertension
2. Cyanotic spells with H/O squatting 2. Congenital heart disease
3. Recurrent respiratory tract infection 3. Rheumatic heart disease
4. Any murmur or cardiac lesion detected
4. Ischaemic heart disease (IHD)
at school
5. Hypertension, diabetes mellitus, IHD 5. Obesity, diabetes, dyslipidaemia
6. Thyrotoxicosis 6. Sudden (cardiac) death
How to diagnose congenital / early onset cardiac disease ?
1. History with ailments since birth/childhood with special reference to squatting.
2. Bulged precordium.
3. Clubbing with cyanosis plus polycythemia.
4. May be associated with dwarfism.
What is ‘precordium' ?
It is the anterior chest wall which overlies the heart. In health, it is slightly convex and associated
with a smooth contour. The different deformities are :
a) Bulging - Early onset and longer duration cardiac diseases (e.g., VSD, rheumatic heart diseases),
pericardial effusion, scoliosis, mediastinal tumours, left-sided pleural effusion.