Examination

Question 1

Mitral Stenosis: symptoms, examination findings

Answer 1

Symptoms: Dyspnoea, orthopnoea, PDN, haemoptysis (ruptured bronchial veins), ascites, oedema, fatigue (pulmonary hypertension)

Examination:

• General: tachypnoea, mitral facies, peripheral cyanosis (severe)
• Pulse and BP: normal/reduced in volume (decrease CO), AF (due to left atrial enlargement)
• JVP: normal, prominent a wave if pulmonary hypertension, loss of a wave if AF
• Palptation: tapping apex beat (palpable S1), palpable P2 if PHTN, diastolic thrill on L) side (rarely)
• Auscultation: Loud S1 (valve cusps widely apart at end of S1- also indicates valve cusps mobile), loud P2 if PHTN. Opening snap (high LA pressure forces valve cusps apart). Low pitched rumbling diastolic murmur (bell, left lateral position).

Question 2

Mitrial Stenosis: Signs indicating severe disease

Answer 2

Small pulse pressure, soft first heart sounds (immobile valve cusps), early opening snap (due to increased LA pressure), long diatolic murmur (persists as long as there is a gradient), diastolic thrill at apex, signs of pulmonary hypertension

Question 3

Causes of Mitral Stenosis:

Answer 3

Rheumatic
Severe mitral annular calcification - sometimes associated with hypercalcaemia and hyperparathyroidism
After mitral valve repair for mitral regurgitation (rarely)
Congential parachute valve (all chordae-tendinae insert into one papillary muscle) - rare

Question 4

Hill’s sign and cause

Answer 4

Systolic BP in leg > 60mmHg compared to upper limb

Severe aortic regurgitation

Question 5

Causes of canon a waves

Answer 5

Atrial contraction against a closed tricuspid valve

• complete heart block
• Ventricular tachycardia, ectopics
• nodal rhythm
• single chamber ventricular pacing

Question 6

Causes of a dominant A wave in JVP

Answer 6

A wave for atrial contraction - large when increased atrial pressure

• tricuspid stenosis
• pulmonary hypertension
• pulmonary stenosis

Question 7

Causes of dominant V wave in JVP

Answer 7

V for volume filling

- tricuspid regurgitation

Question 8

Cause of absent x descent in JVP

Answer 8

Atrial fibrillation

Question 9

Causes of exaggerated X descent in JVP

Answer 9

X descent = fall in atrial pressure during ventricular systole
Exaggerated in acute cardiac tamponade, constrictive pericarditis

Question 10

Cause of sharp y descent

Answer 10

Opening of tricuspid valve

• severe tricuspid regurgitation
• constrictive pericarditis

Question 11

Cause of slow y descent in JVP

Answer 11

• tricuspid stenosis

- right atrial myxoma

Question 12

Causes of elevated JVP

Answer 12

Right ventricular failure 
Tricuspid stenosis or regurgitation 
Pericardial effusion or constrictive pericarditis 
Superior vena cabal obstruction 
Fluid overload
Hyper dynamic circulation