1/21. Expeditious diagnosis of primary prosthetic valve failure.Primary prosthetic valve failure is a catastrophic complication of prosthetic valves. Expeditious diagnosis of this complication is crucial because survival time is minutes to hours after valvular dysfunction. The only life-saving therapy for primary prosthetic valve failure is immediate surgical intervention for valve replacement. Because primary prosthetic valve failure rarely occurs, most physicians do not have experience with such patients and appropriate diagnosis and management may be delayed. A case is presented of a patient with primary prosthetic valve failure. This case illustrates how rapidly such a patient can deteriorate. This report discusses how recognition of key findings on history, physical examination, and plain chest radiography can lead to a rapid diagnosis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/21. Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle.A 61-year-old man was admitted with acute posterior myocardial infarction and, on physical examination, was shown to have a mitral regurgitation (MR) murmur. Transthoracic echocardiography (TTE) showed severe hypokinesis of the posterior wall and severe MR by color flow. Right heart catheterization with a balloon-tipped catheter revealed a pulmonary artery wedge pressure of 30 mmHg. No 'step-up' was seen in blood samples from the right atrium and right ventricle. On angiography, a subtotal occlusion of the mid circumflex artery was found which was angioplastied and stented. As the patient's clinical condition did not improve, he underwent transesophageal echocardiography (TEE) for further evaluation. This showed complete rupture of the posteromedial papillary muscle. The patient underwent urgent surgery with successful mitral valve replacement. The postoperative course was uncomplicated, and clinical improvement seen. This case report underscores the value of TEE in accurate preoperative diagnosis of papillary muscle rupture by providing preoperative anatomic details of the mitral valve apparatus and surrounding structures.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/21. endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child.Varicella is generally a benign, self-limited childhood illness; however, severe, life-threatening complications do occur. A live, attenuated vaccine exists to prevent this illness, but controversy remains concerning the need to vaccinate children for what is generally a benign, self-limited disease, although more states are currently recommending this vaccine. We report a previously healthy 3-year-old who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed group A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocarditis of a normal heart valve. We are unaware of previous reports of endocarditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, aortic valve endocarditis was diagnosed. A 6-week course of intravenous penicillin g was administered. Two weeks after the initiation of therapy, the diastolic murmur was harsher, and echocardiography revealed a large vegetation on the posterior leaflet of the aortic valve, with severe aortic insufficiency and a dilated left ventricle. The patient subsequently developed congestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worsening aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by aortic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GABHS after varicella, illustrates the need for the health care practitioner to consider both common and life-threatening complications in patients with varicella. While cellulitis, encephalitis, and septic arthritis may be readily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superinfection should also be entertained. The case we report is unique in that the patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally normal heart with a previously unreported pathogen. Although a child may have been vaccinated against varicella, the chance of contracting the virus still exists and parents should be informed of this risk. group A beta-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/21. mitral valve plasty for mitral regurgitation after blunt chest trauma.A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
5/21. mitral valve endocarditis: an uncommon cause of myocardial infarction.A 39 year old woman presented with acute anterior myocardial infarction. At coronary angiography the distal left anterior descending coronary artery (LAD)was occluded despite otherwise normal coronary arteries. The LAD was successfully recanalized using PTCA. Subsequently, a transesophageal echocardiogram revealed vegetations and a significant incompetence of the mitral valve.blood cultures identified out enterococcus faecalis. Despite intra-venous antibiotic treatment guided by sensitivity testing, the patient ultimately required elective mitral valve replacement. During a prior outpatient diagnostic work-up of fever/malaise, the diagnosis of infective endocarditis was not made.This case conveys two main messages: 1) because the history and physical sings of bacterial endocarditis can be subtle or non-specific, the first step to diagnose infective endocarditis is to include it in the differential diagnosis. 2) percutaneous coronary intervention is an effective treatment of septic embolic occlusion of a major coronary artery.- - - - - - - - - - ranking = 0.11517603886732keywords = physical (Clic here for more details about this article) |
6/21. High output heart failure 8 months after an acquired arteriovenous fistula.Congestive heart failure (CHF) due to hyperkinetic states can occur in systemic diseases and in arteriovenous fistulas. An 18 year old Turkish male patient complaining of dyspnea and palpitations, who had suffered a stab wound to his abdomen eight months earlier, was admitted to our clinic. auscultation revealed a systolodiastolic murmur over the entire abdomen. Chest x-rays demonstrated significant cardiomegaly. Echocardiography revealed biatrial enlargement and significant mitral and tricuspid regurgitation accompanied by dilatation of the inferior vena cava. Right heart catheterization showed increased oxygen saturation at the inferior vena cava. A diagnosis of an aortocaval fistula was made by aortography. The symptoms subsided and valvular regurgitations ceased alter surgical correction. This rare case demonstrates the significance of routine physical examination and history of the patient.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/21. Traumatic aortic and mitral valve injury following blunt chest injury with a variable clinical course.Blunt trauma is uncommonly followed by intracardiac valvar injuries. The resulting valvar insufficiency rapidly or progressively leads to congestive heart failure or death unless surgically corrected. Three patients with sustained blunt chest trauma were found to have two aortic valve and one mitral valve ruptures. They had variable clinical courses. However, after the diagnosis was established, surgical intervention was attempted promptly, which consisted of two aortic valve replacements and one mitral valvoplasty. Their postoperative courses were uneventful. Careful observation and repeated physical examination, aided by echocardiography, were required after the blunt chest trauma.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
8/21. Non-rheumatic acute mitral insufficiency caused by ruptured chordae tendineae.Five patients with proved mitral insufficiency caused by ruptured chordae tendineae were examined. Two patients came to autopsy without cardiac cateterization. Three patients, who had cardiac cateterization and surgical replacement of their mitral valves, improved dramatically. Two additional patients have been clinically diagnosed and have had corroborative cardiac catheterization and are being observed in anticipation of possible future valve replacement. Similar findings in these seven patients include adult onset of a characteristic systolic heart murmur which mimics aortic valvular stenosis, acute pulmonary edema associated with massive mitral insufficiency in the face of a normal sized or only minimally enlarged left atrium, and variable size of the left ventricle. In none of the patients were there historical or physical findings of trauma or rheumatic or bacterial endocarditis. A wide spectrum of clinical courses may be explained by the variable number of ruptured chordae tendineae at the time of clinical presentation. Although the incidence and etiology are uncertain, we believe this entity is not uncommon. Myxomatous degeneration of the connective tissue of the heart was present, but the cause remains unknown.- - - - - - - - - - ranking = 0.11517603886732keywords = physical (Clic here for more details about this article) |
9/21. Management of valvular heart disease: an illustrative cases approach.As indicated by the 22 illustrative cases included in this monograph, a stepwise approach to the assessment of valvular heart disease provides the information necessary to make good clinical decisions. The ECG and chest x-ray add useful information to the history and physical examination. echocardiography, doppler, and color flow Doppler techniques have an important role in defining the presence and severity of valvular stenosis and regurgitation. Nuclear techniques provide useful information about global biventricular systolic function, regional wall motion, and myocardial perfusion. Exercise testing is most valuable in confirming objectively the patient's functional status and exercise tolerance. Newer imaging techniques, such as cine CT and MRI, are capable of displaying and measuring cardiac chamber size and myocardial thickness; however, visualization of the cardiac valves and demonstration of flow abnormalities are difficult, limiting the current usefulness of these techniques in patients with valvular heart disease.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
10/21. Pulsus alternans with alternation of mitral flow and motion patterns.A 41-year-old man with dilated cardiomyopathy had persistent pulsus alternans on physical examination and on cardiac catheterization. On M-mode echocardiography patterns of mitral valve diastolic motion showed alternation such that the E phase was longer and the A phase shorter after stronger ventricular contractions. At faster rates the A peak was apparently absent in alternate diastoles. Doppler recordings of mitral flow exhibited alternation such that the peak velocity and duration of early diastolic flow were larger after stronger ventricular contractions; diastolic mitral regurgitation was noted only in such (alternate) diastoles.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
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