Today,s photo (Case 94) 16/8/2014 Mitral stenosis The murmur of mitral stenosis is best heared by asking the patient to exercise and then turning on his left side . The pulse may or may not be of small volume ,but will never be of large volume in pure mitral stenosis . Locally : Note that the apex beat is tapping in character with parasternal heave ,due to right ventricular enlargement .Also feel for a diastolic thrill at the apex . The murmur is an apical rough rumbling mid-diastoolic one and best heared in the left lateral recumbant position .Exercising the patient makes the murmur more prominent , If the patient is in sinus rhythm there may be presystolic accentuation of the murmur which disappear with the onset of atrial fibrillation . Note that the first sound is loud . Check if there is more than one valvular lesion ,and if mitral incompetence is also present , decide which one is the dominant lesion ,loud first heart sound favour mitral stenosis ,whereas faint first heart sound accompanied with third heart sound is more suggestive of mitral incompetence . Elswhere : Look for malar flush , remember that malar flush is also present with other conditions causing pulmonary hypertension . Examine the pulse which is usually normal volume ,but rarely with severe degree of stenosis may be of small volume . Look for any signs of congestive cardiac failure . Look for signs of infective endocarditis e.g clubbing .petechial hemorrhages ,splinter nails ,osler,s nodes ,janeway lesions and splenomegaly .(Q) How is the patient affected on developing atrial fibrillation ? (A) (1) Chances of heart failure are increased . (2) Chances of infective endocarditis are decreased . (3) presystolic accentuation disappears . (4) Incidence of thromboembolism and stroke are increased .
Posted on: Sat, 16 Aug 2014 11:49:50 +0000
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