Case presentation
Presenter- Dr. Gyaneshwar, JR(DNB)
Moderator- Dr. Deepak Sharma, Asst. Prof
Department of General Medicine
Patient Particulars
• Patient name: Mr. Devendra
• Age: 66 years
• Sex: Male
• Address: Neemka, Gr Noida, Gautam Buddha Nagar
• Occupation: Mason
• Date of admission: 17/07/2023
• Date of examination: 18/07/2023
Chief Complaints
• A 66 years old male, mason by occupation presented to our
department with the following chief complaints:
• Breathlessness for 4 years
• Chest pain for 3 years
• Multiple episodes of loss of consciousness for 3 years
• Palpitations for last 1 year
History of present illness
The patient was apparently asymptomatic 4 years back when he developed
breathlessness which was:
• Initially insidious in onset,gradually progressive; there was no limitation of
activity but breathlessness on exertion such as climbing 2-3 flight of stairs
(NYHA grade II)
• It progressed over next 2yrs such that he gets breathless on routine work
like going to washroom ( grade III)
• He also c/o breathlessness after around 1-2hrs of sleep at night after
which he wakes up feeling air hunger (Paroxysmal Nocturnal Dyspnea)
• Now for the last 2 months he feels breathless even at rest (NYHA grade IV)
and worsens immediately after lying supine(Orthopnea)
• Not a/w wheeze, cough, seasonal exacerbations
History of present illness
The patient also complained of chest pain for 3 years which was:
• intermittent
• retrosternal site
• constricting nature
• occurred at the time of exertional activtity
• relieved at rest
• Not associated with episodes of sweating
History of present illness
The patient also complained of multiple episodes of loss of consciousness for the
last 3 years which were:
• Sudden in onset with history of falling on ground.
• Total duration <1min and he regained consciousness immediately.
• Most episodes occurred while on strenuous activity
• Not associated with abnormal movements, frothing from mouth and urinary
incontinence
History of present illness
The patient also complained of palpitations for the last 1 year which were:
• Insidious onset , gradually progressive
• Initially palpitations experienced only with exertion (grade 1) lasting for
5mins,regular in rhythm and relieved at rest
• Not associated with emotional disturbance or anxiety.
• No h/o bluish discolouration of skin or mucous membranes
• No h/o cough ,hemoptysis
• No h/o fever, migratory joint pain or involuntary movements during
childhood
• No history of recurrent chest infection.
• No abdominal distension or abdominal pain
Past History
• Known case of hypertension since 20 yrs and on irregular medications
• H/o Hospitalization 3yrs back for chest pain where he was diagnosed
with heart disease and advised surgery but patient denied for
surgery(No records available)
• No h/o Diabetes, Asthma, Tuberculosis, Epilepsy or any other chronic
disease.
Personal History
• Diet -mixed
• Appetite -Normal
• Sleep -Disturbed
• Bowel habits- Normal
• Bladder habit- Normal
• Chronic smoker, 20pack years.
• Non alcoholic.
Family History
• Born of a non consanguineous marriage
• No family history of sudden cardiac death
• No history of cardiac disease in family members
• No history of TB contact
Differential Diagnosis (on basis of
history)
1. Valvular Heart Disease
2. Ischemic heart disease/Cardiomyopathy
3. Arrythmias
4. Anaemia
5. Hypertensive heart failure
6. COPD
EXAMINATION
• 66 years old male, who is moderately built and moderately nourished, is
conscious, cooperative and oriented to time place and person, sitting on bed,
appears tachypneic.
Vitals :
• Temperature - 98.4 F, Afebrile
• Pulse- 80bpm, Regular, low volume pulse
Character - slow rising and late peak,
No radio radial or radio femoral delay
All Peripheral pulses felt.
• Blood Pressure - 90/70 mmhg, Pulse pressure - 20mmhg
• Pallor- Absent
• Icterus- Absent
• Cyanosis - absent
• Clubbing- Absent
• Edema- Absent
• No lymphadenopathy
• Osler nodes, Janeway lesions, splinter hemorrhages absent
• Jugular venous pressure- Not raised
Systemic Examination(CVS)
INSPECTION AND PALPATION
• Chest wall symmetrical with no precordial bulge
• Trachea is in midline
• Apical impulse visible in 5th ICS in midclavicular line confined to one
intercostal space. On palpation- apex beat is forceful and well
sustained(heaving)
• No parasternal heave present
• Thrill present at base of the heart (aortic area)
• No epigastric pulsations
Systemic Examination(CVS)
AUSCULTATION
• Mitral area - S1,S2 present, No murmur
• Tricuspid area - S1, S2 present, No murmur
• Aortic area – S2 present with no splitting. Early and mid systolic
murmur present,crescendo and decrescendo in character, heard by
diaphragm of stethoscope, radiating to carotid arteries. Ejection click
in not audible
• Pulmonary area – S2 present with no splitting.
Systemic Examination
• Other systems- Respiratory, GIT and CNS were examined and no
abnormality was detected.
SUMMARY
• 66 yrs old chronic smoker male , mason by occupation with background
history of heart disease having dyspnea on exertion (NYHA I-IV),
intermittent chest pain(angina), multiple syncopal attacks and
palpitations with low volume pulse and narrow pulse pressure,heaving
apical impulse, systolic thrill with early and mid systolic murmur in
aortic area radiating to carotid arteries and single S2 at the base of the
heart.
INVESTIGATIONS
• Hb - 14.6gm/dl
• TLC – 8300
• SGOT/SGPT - 76/50
• Urea/ creatinine - 23/ 0.9
• Trop I - 0.01(Negative)
ECG
Left axis deviation,
Left ventricular
hypertrophy with
pressure type strain
pattern in lead 1,
aVL, V5, V6
Chest X-Ray
• Slight rounding of
cardiac apex
(hypertrophy without
dilation)
• Dilated proximal
ascending aorta
along right heart
border
Echocardiography
• Concentric LVH
• No MR, No TR
• Aortic stenosis with Aortic valve area – 0.8 cm2(SEVERE)
• Aortic jet velocity 4m/sec
• LVEF ~20%
• No pericardial effusion
• No clot in LA or LV
• IVC - compressible.
Diagnosis
• Valvular heart disease in form of Severe Aortic Stenosis with HFrEF
with no evidence of pulmonary arterial hypertension and infective
endocarditis or embolic phenomena. Patient is currently in NYHA-IV.
Management
• Patient was advised to avoid strenuous physical activities
• Maintain hydration and euvolemia
• Medications - Beta blockers, ACE inhibitors, Nitroglycerin(for anginal
pain), statins.
• ADVISED AORTIC VALVE REPLACEMENT SURGERY AND REFERRED TO
HIGHER CENTRE FOR THE SAME
Aortic Valve replacement
1. Mechanical aortic valve
• Risk of thromboembolism
• More durable
2) Bioprosthetic valve
• Limited durability
