Tuesday, May 11, 2010

Post 9: Mitral Stenosis

I am praying for a Cardio case for my OSCE.

But at the same time I hope it is not Mitral Stenosis though.

To date, I have yet to catch a murmur, and get it right. Usually a pansystolic would be heard as ejection systolic, and vice versa. Diastolic murmur doesnt exist in my CN8.

Anyways; after examine the patient in the station, paling best if can really get all the signs.

This patient of mine has a malar flush on his face on general inspection, and irregularly irregular pulse on examination. On examination of the chest, he has a left submammary scar. Apex beat is tapping in nature, not displaced. On auscultation, the first heart sound is very loud, with a soft second heart sound, and a rumbling, mid diastolic murmur heard. It is of 4/6 intensity, loudest at the apex, accentuated by the patient lying on his left and holding his breath in expiration. There is no radiation noted. There is no signs of infective endocarditis noted on my examination, and no signs of right ventricular failure. These findings are in keeping with my diagnosis of mitral stenosis.

A few clues I found helpful for myself:

1. Apex beat.

It is always very hard to remember or even understand apex beat. My problem is firstly, where is the apex beat? I dont know how to count ribs also. But i usually pretend to count and just show that is in 5th intercostal space mid clavicular line. So how to remember the nature of apex beat?

Apex Beat. - I only remember 4 types of characters. Heaving, Thrusting, Tapping and Double Impulse.

Heaving - H = Hypertension = Pressure overload. So I remember things that can give pressure overload. So it is aortic stenosis, HOCM, systemic hypertension. Ya, thats it lo. And because it is pressure, it causes hypertrophy which is NOT dilation. So no displacement!

HEAVING= Pressure.

Thrusting - Because H - hypertension, maka this T must be for volume overload. So things that can cause volume overload. For the sake of murmur, i only remember it together with valve regurgitation, coz more blood in the ventricle mah. Logic? And more blood, need more space, dilation loh. So it is aortic regurg and mitral regurg gives thrusting apex beat.

THRUSTING = volume = dilation = displaced.

If you say heaving apex beat and displaced = you heading shit liau.

And the last two is easy. Double beat = HOCM, wont have a chance to feel that case at all. i hope.

TAPPING = loud first heart sound. = Mitral stenosis, coz thats the last murmur we had left with.

2. Opening Snap and rumbling shit.

I think, thank goodness, i am using a cheap stets. Chance of hearing a rumbling shit is very small, so just ignore that part of the knowledge. Opening snap, u got to listen damn careful, and i have never heard anyway.

A good point to know, if asked, how to quantify the severity, it would be the duration of the rumbling, and the duration between opening snap and second heart sound.

3. I'll talk about AF later. I think AF is very likely to be asked if they have a Mitral stenosis case. Too many parts to explore.

Study la read blog read blog.

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