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Aortic Regurgitation Case

Mr. ABC, a 45-year-old male, presents with palpitations and breathlessness, with a significant history of rheumatic fever, suggesting moderate chronic aortic regurgitation likely due to rheumatic heart disease. His examination reveals characteristic signs such as a high-volume pulse, wide pulse pressure, and specific heart murmurs. The patient shows no signs of complications like congestive heart failure or infective endocarditis at this time.

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deepalirangra1997
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6 views8 pages

Aortic Regurgitation Case

Mr. ABC, a 45-year-old male, presents with palpitations and breathlessness, with a significant history of rheumatic fever, suggesting moderate chronic aortic regurgitation likely due to rheumatic heart disease. His examination reveals characteristic signs such as a high-volume pulse, wide pulse pressure, and specific heart murmurs. The patient shows no signs of complications like congestive heart failure or infective endocarditis at this time.

Uploaded by

deepalirangra1997
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Aortic Regurgitation

Mr. ABC, 45 yrs. old hindu male, construction site worker by


occupation, resident of Mumbai Central , came with chief
complaints of :-

Palpitations since 5 months


Breathlessness since 3 months

Mr. ABC was apparently alright 5 months back when he started


to experience an uncomfortable awareness of his own
heartbeats which developed insidiously & was occurring
intermittently initially.
The patient recalls that these palpitations were of throbbing &
pounding in nature and not associated with sudden onset &
termination, no post palpitation diuresis (r/o PSVT), they were
not irregular (r/o A.Fib/Flutter), there was no sensation of
missed beat followed by heavy beat (r/o PAC/PVC), not
associated with loss of consciousness(r/o V.tach), or not related
to drug intake. Moreover, he says that palpitations were
accentuated on lying down (whenever he used to go to bed) &
were also precipitated by emotional stress & while carrying out
routine activities (NYHA Grade lll)
Patient also started to experience breathlessness around 3
months back which was insidious in onset, progressed
gradually, exertional in nature (he told that he was accustomed
to carry 30kgs cement bag on his back from point A to B, but
since last few weeks he started to notice that he becomes
breathless after completing the same activity – NYHA Grade ll),
not associated with seasonal, positional, diurnal variation or
chest pain.
The patient also told that a few days ago he had two episodes
of acute breathlessness 2-3 hrs after sleeping, which made
him discontinue his sleep, wake up & gasp for air by breathing
heavily to normalize again within 30-40 minutes.

Etiology :- No H/O
-Chest pain, angina(r/o IHD)
-Recent trauma to the chest wall
-Fever with chills, i.v. drug abuse (r/o IE)
-Rash over face, photosensitivity, swelling of joint (r/o CTDs like
SLE,RA)
-Joint pain, lower back stiffness, red eye (r/o ankylosing
spondylitis)
-Similar complaints in family members (congenital valvular
diseases like Bicuspid aortic valve)
-Previous heart surgery (r/o prosthetic valve damage)
-Abdominal pain, diarrhea, vomiting (r/o CD, Whipple's)
-STD exposure/painless ulceration in genital region (r/o
syphilis,)

Complication :- No H/O
-Sudden onset of dyspnea, worsening of dyspnea (r/o acute
LVF)
-Nocturnal angina
-B/L pedal edema (r/o right sided CCF)
-Rapid & irregular heartbeats (r/o any arrhythmias)
-Hoarseness of voice/dysphagia (r/o Ortner's syndrome)
- CVA (Cardioembolic stroke)
- Fever ( IE)

Past History:- Mr. ABC recollects he had an infection in


childhood (16 yrs) which was characterized by fever along with
joint pain & reddish skin lesions ,which in turn occurred
following an episode of sore throat, due to which he was
admitted in hospital. He clearly remembers taking injection for
the same every 3 weekly for about 5 yrs. (Indicating an episode
of Rheumatic fever in the past) .
No H/O Hypertension, DM or any other significant
medical/surgical condition.

Personal History:- Patient says that most of the nights he can


sleep comfortably, but few of the times he can’t have a proper
sleep due to episodes of acute dyspnea. Patient denies any
addiction. Bowel & bladder habits are normal.

Family history:- No H/O similar complaints in the family


members, no H/o of sudden cardiac death in family (r/o HOCM
& DCM)

Socioeconomic history :- Mr. ABC belongs to lower middle class


according to modified kuppuswamy scale.

Provisional diagnosis :- My patient Mr. ABC, who came with c/c


of palpitations since 5 months & breathlessness since 3 months
with a significant past history of Rheumatic fever most probably
can be a case of Rheumatic heart disease causing regurgitant
lesion on the left side of the heart like Aortic regurgitation .
DD- Mitral Regurgitation
- Cardiomyopathy
General examination:-
Patient is conscious, cooperative & well oriented to time, place
& person, averagely built, well nourished with BMI of 23 kg/m2
& is examined in supine position with informed consent .
Afebrile to touch
Respiratory rate :- 16 /min
Pulse :- 84 BPM in right radial artery, regular rhythm, high
volume/ bounding in nature & on suddenly lifting the arm up
diastolic descent (runoff) present (indicating water hammer
pulse). Neither there is any inequality nor any delay. Arterial
wall isn’t thickened & all peripheral pulses were easily palpable.
BP :- 130/50 mm Hg measured in right brachial artery in supine
position i.e. high systolic & low diastolic BP indicating there is
wide pulse pressure.
Therefore, peripheral signs due to wide pulse pressure are
looked for & those which were observed were:-
-Visible capillary pulsations at nail beds i.e. blanching & quick
refill (Quincke's sign)

-Prominent digital artery pulsations


-High volume, collapsing/ Water hammer pulse
-Easily visible carotid artery pulsations/ Dancing carotids
(Corrigan's sign)
-Pulsations of Uvula (Muller's sign)
-Booming sound produced after pressing stethoscope over
femoral artery ~ ‘Pistol Shot’ sounds (Traube's sign)
-SBP at popliteal artery (170/80 mm Hg) 40 mm Hg greater than
that in brachial artery (Hill's sign- moderate AR )

JVP – not elevated


No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
No features suggestive of Marfan Syndrome, Ehler Danlos
syndrome or any CTD
No peripheral signs of infective endocarditis seen

Systemic examination:-

CVS:-
Inspection :- Chest is B/L symmetrical, Apical impulse seen over
a diffuse area in roughly around left 6th ICS & seems to be
displaced down & out.
No scars, sinuses ,dilated veins
Palpation :- Inspectory findings were confirmed. Apex beat is
felt in left 5th & 6th ICS 1.5 cm lateral to MCL i.e. displaced
laterally & inferiorly & has hyperdynamic character.
No thrills/palpable heart sounds felt .

Auscultation:-
-Heart sounds :- Soft S1 heard in mitral & tricuspid areas & Soft
S2 in aortic & pulmonary areas.
S3 & S4 NOT heard.
-Murmurs :-
1. Early diastolic, decrescendo (Grade lll) , high-pitched, soft-
blowing murmur is heard in left 3rd ICS (neoaortic area) along
the left sternal border, in sitting & leaning forward position, in
full expiration, with diaphragm of stethoscope.
2. Ejection systolic (flow) murmur, high pitched, radiating to
carotids is also heard (however there isn’t any delayed carotid
upstroke , instead – Corrigan sign +)
3. No evidence of any low-pitched, rumbling mid-diastolic
murmur (indicating the absence of Austin Flint Murmur)
Dynamic auscultation:- The intensity of the murmur increases
with isometric hand grip exercise & and on squatting. However,
it’s intensity decreases in Phase 2 of Valsalva maneuver & on
standing.
GIT :- No tenderness/organomegaly found
RS :- No abnormal/adventitious breath sounds heard
CNS :- No signs of focal neurological deficits seen

Diagnosis :- My patient, Mr. ABC, 45 years old male, with


palpitations since 5 months, breathlessness since 3 months & 2
episodes of PND, with H/O rheumatic fever in childhood , is a
case of Moderate Chronic Aortic Regurgitation most likely
etiology being chronic rheumatic heart disease without any
complication such as CCF , Pulmonary HTN , without signs of
IE & currently in NSR .

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