pgdcc 2012 interactive clinical

7/31/2019 PGDCC 2012 Interactive Clinical

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PGDCC 2012

Interactive Clinical Case Session


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CASE No.1:

45yrs female presented with increasing SOBE and low-

grade intermittent fever of 15 days duration.She was suffering from progressive SOBE since 16yrs of

age. In the initial years she had few episodes of SOB in the

late hours of night for which she had to get up from the sleep,

and sit upright and cough out pink, frothy sputum for gettingrelief. She had one episode of hemoptysis at the age of

19yrs.Presently she was having SOB on routine activity.

She also suffered from palpitation since 24yrs of age. At

the age of 28yrs, she had one episode of sudden increase in

palpitation followed by transient weakness of left upper limbwhich lasted for few hours. There was no residual weakness

and no recurrence of such episode again.

She was also suffering from chest pain on exertion for

last 1yr.


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Questions:

1.Anymore clarification in the history?2.What is the provisional diagnosis? Why?

3.What is the reason for SOB in the late hours of night?

4.What is the cause of hemoptysis?

5.What is the cause of palpitation?

6.What is the cause of transient weakness of left upper

limb?

7.What is the cause of chest pain on exertion?

8.What is the cause of fever?


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On examination her pulse was 84bpm, of good volume with a rapid

upstroke. Her blood pressure in the right upper limb was 110/60/0 mm of

Hg and right lower limb 160/64/0 mm of Hg.

Cardiovascular examination revealed the following-Palpation:

Apex- left 6th inter-costal space 2.5cm outside the

mid-clavicular line.

Left parastenal pulsation present

Auscultation:

S1 P2 ?OS+ / ?LV S3 +Mitral Area- Pan-Systolic Murmur Gr.III/VI on

Handgrip

Mid-diastolic rumbling Murmur on

Handgrip

Pulmonary Area Ejection Systolic Murmur Gr.II/VIAortic Area & Neo-Aortic Area

Ejection Systolic Murmur Gr.II/VI

Radiating to both carotids ; on Handgrip

Early Diastolic Murmur occupying 2/3rd of diastole ; on Handgrip

Abdomen- Spleen just palpable


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Questions:1.Any more clarifications ?

2.How to differentiate between OS and LV S3 ?

3.What is the final diagnosis ?

4.Which lesion is predominant ?5.Is ESM in aortic area due to AS or AR alone ?

6.Can all the findings be explained by severe AR?

7.What are the peripheral signs of AR ?

8.Can MDM be the Austin-Flint murmur?


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ECG- LVH with diastolic strainCXR- Cardiomegaly


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CASE 2:

40 yrs old female presented with progressive SOBE and

easy fatiguability of 3yrs duration.

She had SOB on unaccustomed activities initially but at

present she was breathless even on routine activities.Shefrequently suffered from cough and cold.

She also had palpitations over last 2 yrs which increased on

exertion.

She was hypertensive controlled on medication and

euglycemic.

She was married with two children. Both the deliveries were

uneventful.


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Questions:1.What is the probable diagnosis from the history

2.What is the cause of late presentation of symptoms

3. Can only hypertension be responsible for her

symptoms?

4. Why she was not symptomatic during pregnancy?


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On physical examination her pulse was 84bpm irregularly

irregular.Her blood pressure was 140/90 mm of Hg.

JVP was of normal height and the A wave is equal to the

V wave.

Cardiovascular examination revealed the following-

Palpation-

Apex Left 5th intercostals space just outside the MCL

line; diffuse in characterLeft parasternal lift present

Pulmonary pulsation present with a systolic thrill.

Auscultation-

S1 loudS2 loud. ? Wide split/? OS

Mitral Area MDM

Pulmonary Area ESM Grade IV/VI on inspiration


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Questions:1. Why A wave is is equal to V wave?

2. Is systolic thrill consistent with this condition?

3. What is the mechanism of wide split in ASD?

4. What will be the ECG & X-Ray findings in thiscondition ?

5. Which investigation will be confirmative?

6. What will be the management for this condition

role of device therapy or surgery?


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CASE No.3:

12yrs male presented with history of bluish discolouration of

nails and squatting for last 7yrs.

His mother told that he suffered from blue spells frequently

on crying,feeding or bowel movement during the 1st year oflife.

She also said that he had delayed milestones of

development.

The birth of the child was uneventful.He had two other

siblings who were normal.


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Questions:

1.What is the probable diagnosis?2.Why the symptoms and signs do not occur immediately

after birth?

3.What is cyanotic spell and why it occurs?


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On physical examination he was underdeveloped.

His pulse was 84 bpm, normal in character.His blood

pressure was 120/80 mm of Hg.His JVP was normal.

Cardiological examination revealed the following

Palpation-

Apex- Left 5th Intercostal space on the Mid-Clavicularline.

Lower left parasternal and sub-xiphoid pulsations present.

Auscultation-

S1 normal

S2 loud and single.Pulmonary Area and Left 3rd Intercostal space-

ESM grade III/VI on handgrip.


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ECG P-pulmonale

RAD

RVH with strainCXR Normal pulmonary vascularity

Normal cardiac size

Upturned apex


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Questions:1.Can this be Eisenmengers Syndrome?

2.Can this be severe valvular PS with reversal of shunt

through PFO ?

3.What are the typical anatomical components in this

condition?4.What is the developmental basis for this disease?

5.What are the typical findings of this condition ?

6.What is the investigation to confirm the diagnosis ?

7.What is the medical management for cyanotic spells?8.What is the surgical management- palliative and corrective?

9.What are the complications of TOF?


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CASE No.4

19yrs old female presented with Syncope and chest pain on

exertion and shortness of breath with mild exertion.

Her symptoms started early childhood and was detected to

have cardiac problems during early childhood with frequent

cough and cold.


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Questions:

1.What type of heart disease is present in this

patient?

2.What is the probable diagnosis?3.What is the mechanism of syncope and chest

pain?

4.Why not it is Tetralogy of Fallot ?


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Physical Examination:-Slender appearance with dusky skin

Cyanosis, clubbing hands and feet;

Pulse: 88/bpm regular; BP: 110/70 mmhg

Peripheral pulses normal.JVP: 9 cms with prominent a wave.

Left parasternal heave; S1- Normal, S2- Loud and single.

Ejection click over the pulmonary ares.

Chest and abdominal examination : normal.


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Investigation:-

ECG,

X-Ray Chest:PA ,Echo cardiogram (Done)

Arterial O2 Sat 75% , Hb: 21gms/dl; Haematocit : 62%


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Questions:

1.What is the correct diagnosis?

2. Is cardiac catheterisaton nessecery?

3.What is the outcome of pregnancy and foetal health?4.What is the management of this condition medical /surgical

or anything else?


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CASE No.5

A 21 yr old male came to the hospital OPD for upper

respiratory tract infection and incidentally found to have

hypertension but without any medications.

He denies any chest pain, dysponea, palpitations or

syncope. There is no other remarkable history.


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Questions:

What is the probable diagnosis in this patient?


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Physical Examination:

Normal in appearance; no Cyanosis or clubbing;

BP: 158/100mmhg;

JVP- normal

Cardiac impulse- normal

S1- normal; S2- normal; S4 present

Ejection Click over the aortic areaGrade II/ VI ejection systolic murmur heard along left

parasternal area

No diastolic murmur heard.

Chest and abdominal examination unremarkable.A soft continuous murmur over the back

Femoral pulses in both lower limbs diminished and

delayed.

Optic fundas- normal


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Questions:1.What is the cause of diminished femoral pulses?

2.What is the cause of the murmur at the back?

3.What can be found on inspection and palpation of the

back ?

4.What is the anatomical basis for this finding?

5.What further investigations need to be done?

6.What are the typical findings in X-Ray Chest:PA

view?7.What is the role of MRI in this condition?

8.What is the role of cardiac catheterisation in this

patient?

9.What are the treatment option modes- Medical/ BalloonAortoplasty/ Surgical repair?

10.What is the chance of Residual hypertension after

intervention or surgical correction?


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THANK YOU

pgdcc 2012 interactive clinical

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