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no difficult terms

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A 35-year-old Malay lady

presented to the Emergency Department

heart felt like skipping a beat or sometimes beat too fast of

two months duration.

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rapid palpitation- fast and forceful heartbeat where heart feels like racing,flopping or fluttering. (rapid palpitations being worse at night- SVT)

shortness of breath on exertion- exertional dyspnea

illicit substances- illegal drugs like heroin,morphine and cannabis

arrhythmia- abnormalities of conduction electrical impuls

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-rapid palpitations being worse at night

-shortness of breath on exertion over the previous week.

-history of recurrent episodes of fever and painful joints and sore throats in the patient’s childhood.

-no history of any psychiatric disorder.

-No history of loss of weight,vomiting or diarrhoea was elucidated.

-no familial history of any inherited arrhythmia disorder.

-no known allergies

-not on any medications.

-She denied any smoking, alcohol or illicit substance abuse

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-rapid palpitations being worse at night -SVT heartbeat 150-220 per min

-shortness of breath on exertion over the previous week -increase workload increase o2 demand- heart cannot pump to meet o2 demand so lack of o2 lead to dyspnea. - due to pulmonary congestion ineffective gasses exchange. ventilation perfusion mismatch

1.(blood flow okay but less o2 intake)

2.(o2 intake okay but blood flow disrupt)

-history of recurrent episodes of fever and painful joints and sore throats in the patient’s childhood- pt already experience multiple time (fever -infection,inflammation or any injuries)(painfull joints-due to artritis due to group A b-hemolytic strep)

-no history of any psychiatric disorder- no mental illness

-No history of loss of weight,vomiting or diarrhoea was elucidated- no hyperthyroidism, no GIT problem

-no familial history of any inherited arrhythmia disorder- low risk factor

-no known allergies- not aware about her health status( no chance to allergy induce cardivascular disease)

-not on any medications- no chronic disease

-She denied any smoking, alcohol or illicit substance abuse- no substances induce sympathetic outflow.

DIFFERENTIAL DIAGNOSIS

valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

mitral valve prolapse - a condition where mitral valves cannot close properly

mitral valve stenosis (commonly affected valve)

sinus tachycardia - increase rate of electrical discharge from SA node

IHD - atherosclerosis can cause IHD

congestive heart failure - causes by no blood flow

hyperthyroidism (most common in women due to hormonal causes)

affected by early menopause due to drop level of estrogen

can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

mental health (due to anxiety and depression or panic attack)

substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

COPD

pulmonary embolism

SVT

Rheumatic heart disease (meet 2 minor jones 2015 criteria)

FURTHER INVESTIGATION

PE -vital sign , auscultation, percussion, palpation (cardiomegaly), inspection

ECG- ST elevation , prolonged PR interval

CXR

echocardiogram

angiogram

lab test - lipid profile test (atherosclerosis), fasting blood glucose, cardiac biomarkers, ASOT( antibody for strep infection), FBC, blood culture and sensitivity, electrolyte

ECG stress test(angina)

CT scan

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A 35-year-old Malay lady - more prone to certain diseases (atheresclerosis/arrhytmias/hypertension/arteriosclerosis)

presented to the Emergency Department - the disease needs to be treated immediately

heart felt like skipping a beat

palpitation (causes : hypertension/stress/anxiety/arrhytmias IHD/valvular disease )

(SA node firing multiple electrical impulse to AV node)

delay AV node conduction can be caused increase refractory period

heart sometimes beat too fast

tachycardia (heart rate more than 100 per minute)

two months duration

indicate the patient has chronic disease

DIFFERENTIAL DIAGNOSIS

valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

mitral valve prolapse - a condition where mitral valves cannot close properly

mitral valve stenosis (commonly affected valve)

sinus tachycardia - increase rate of electrical discharge from SA node

IHD - atherosclerosis can cause IHD

congestive heart failure - causes by no blood flow

hyperthyroidism (most common in women due to hormonal causes)

affected by early menopause due to drop level of estrogen

can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

mental health (due to anxiety and depression or panic attack)

substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

COPD

pulmonary

FURTHER QUESTIONING

HISTORY TAKING (SOCRATES)

site - where is the location

onset - when the palpitations first felt

characteristics - is she has crushing pain / how does it feel

radiation - where the palpitation can be felt other than chest

associated symptoms - is there any associated symptoms (SOB/cough/wheezing sound/headache/orthopnea/chest pain/night sweats/fatigue/weight loss/cachexia/mental distortion-confusing)

time - how long the duration of palpitations / continuous or not

exacerbating factor - smoking/physical activity/medication such as b-agonist/dust exposure

severity - scale based on 1-10

SOCIAL HISTORY

ask about smoking

alcohol intake

occupation

mental health

dietary pattern (coffee addiction)

lifestyle (sleep patterns)

FAMILY HISTORY

is there any family members affected by heart disease

any members have cancer, DM, hypertension, obesity

PAST MEDICAL HISTORY

does she has any surgery before (pacemaker/Artificial valve/stent)

does she had RF or RHD when she was young

does she has IHD or heart failure before this

does she has chronic disease (DM / hypertension/CKD)

DRUG HISTORY

does she take any medications (B-agonist)

SYSTEM REVIEWS

any joint pain/headache/abdominal pain

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1. heat intolerance- feeling of overheat when surrounding temp increase and it may cause dysautonomia- disorder ANS

2. diastolic rumble- heart murmur with an unusual whoosh sound in the heart that occur when diastole occur due to mitral or tricuspid stenosis

3. accentuated - louder or more noticeable

4. distention - swelling or enlargement body part

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1. vital sign- temp normal, HR tachycardia, irregularly irregular, AFib, RR normal, BP normal

2. On physical examination, the patient appeared comfortable and

is fully alert and oriented

3. No evidence of hyperthyroidism like nervousness, heat intolerance, thyromegaly was revealed.

4. The auscultatory findings demonstrated a loud first heart sound, an

opening snap, and a diastolic rumble.

5. Pulmonic valve (P2) sound was accentuated.

6. Lung auscultation revealed bilateral crackles (crepitations) at the lower bases but no rhonchi or wheezing.

7. She demonstrated elevated jugular venous distention to 12 cm H2O

8. demonstrated bilateral pitting lower extremity

oedema

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1. vital sign- temp normal, HR tachycardia, irregularly irregular, AFib, RR normal, BP normal - due low stroke volume causes decrease in the ventricular filling, body is undergoing compensatory mechanism to inc CO

2. On physical examination, the patient appeared comfortable and

is fully alert and oriented - no abnormality of CNS involve

3. No evidence of hyperthyroidism like nervousness, heat intolerance, thyromegaly was revealed. - absence of nervousness, heat intolerance and thyromegaly

4. The auscultatory findings demonstrated a loud first heart sound, - caused by mitral stenosis, valve stiff and narrow

5. an opening snap - caused by mitral stenosis, due to forceful opening of the mitral valve

6. a diastolic rumble- mitral stenosis, carey coombs - characteristics murmur caused by mitral stenosis in RF

7. Pulmonic valve (P2) sound was accentuated - indicate normal closing of pulmonary valve

8. Lung auscultation revealed bilateral crackles (crepitations) at the lower bases but no rhonchi or wheezing. - indicates fluid accumulation, pulmonary oedema

9. She demonstrated elevated jugular venous distention to 12 cm H2O - indicates right atrium prob, right side failure

10. demonstrated bilateral pitting lower extremity oedema - indicates right atrium prob, right side failure

DIFFERENTIAL DIAGNOSIS

valvular heart disease (stenosis - blockage of area of valve will reduce blood flow from left atrium to left ventricle and regurgitation - defects in papillary muscle or connective tissue that cause leaflets flop allowing backflow of blood

mitral valve prolapse - a condition where mitral valves cannot close properly

mitral valve stenosis (commonly affected valve)

sinus tachycardia - increase rate of electrical discharge from SA node

IHD - atherosclerosis can cause IHD

congestive heart failure - causes by no blood flow

hyperthyroidism (most common in women due to hormonal causes)

affected by early menopause due to drop level of estrogen

can affect men but less common (usually caused by grave's disease or other thyroid issues (thyroid nodules / thyroiditis)

mental health (due to anxiety and depression or panic attack)

substance use disorder (caffeine is a stimulant that stimulate SNS/ alcohol/ nicotine/ tablet*)

COPD

pulmonary embolism

SVT

Rheumatic heart disease (meet 2 minor jones 2015 criteria)

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1. Diffuse airspace opacification: filling of the lung parenchyma with material that attenuates x-rays more than unaffected lung tissue.

2. Transesophageal echocardiogram (TEE): cardiac ultrasound procedure where a probe with a transducer is inserted into the esophagus to create the image of the heart. provides clearer image of the heart.

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LEARNING ISSUE CVS CASE 3 with suggested activity

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Lab test: Normal

Imaging Studies:

Chest radiograph and C.T. scan:

1. Diffuse airspace opacification, bilateral pleural effusions

2. ECG - Atrial fibrillation

3. TEE: The left atrium is severely dilated. The right atrium is moderately dilated.

4. There is moderate to severe tricuspid regurgitation.

5. Right ventricular systolic pressure is elevated at> 60mmHg.

6. Left ventricular systolic function is borderline reduced.

7. The flattened septum is consistent with R.V. pressure/volume overload.

8. The right ventricle is mildly dilated. The right ventricular systolic function is hypokinetic.

9. There was severe mitral stenosis.

10. Rheumatic mitral stenosis, features of congestive heart failure.

11. Treatment: beta-blockers, cardiac glycosides, diuretics, anticoagulants.

12. The patient was transferred to a cardiothoracic evaluation of potential percutaneous balloon valvuloplasty of the mitral valve.

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Diagnosis: Rheumatic fever, Mitral stenosis, CHF, Pulmonary edema

1. Diffuse airspace opacification, bilateral pleural effusions

2. ECG - Atrial fibrillation

3. TEE: The left atrium is severely dilated. The right atrium is moderately dilated.

4. There is moderate to severe tricuspid regurgitation.

5. Right ventricular systolic pressure is elevated at> 60mmHg.

6. Left ventricular systolic function is borderline reduced.

7. The flattened septum is consistent with R.V. pressure/volume overload.

8. The right ventricle is mildly dilated. The right ventricular systolic function is hypokinetic.

9. There was severe mitral stenosis.

10. Rheumatic mitral stenosis, features of congestive heart failure.

11. Treatment: beta-blockers, cardiac glycosides, diuretics, anticoagulants.

12. The patient was transferred to a cardiothoracic evaluation of potential percutaneous balloon valvuloplasty of the mitral valve.