Nozar Amiri, M.D., Department of Internal Medicine, California University of Science and Medicine, School of Medicine
Department of Family Medicine University of California Riverside, School of Medicine
A 35-year-old Caucasian woman, Jessica M. is admitted to this hospital with difficulty breathing when engaged in a simple activity like walking up the stairs or going to the mailbox. She complains of numbness in the legs when she climbs the stairs, and numbness in the knees when she kneels. She states that her condition has been getting worse progressively during this time. She has not seen a doctor in the past 20 years because she has not had any medical problems and has no medical insurance.
Five months prior to admission she felt that she could not perform her duties as easily as she used to at the restaurant where she has worked in the past 3 years as a waitress. About seven months ago she started feeling tired sooner than before and felt short of breath when going upstairs. Recently she felt tired and short of breath even when she walked to the bus station to go home as she always did without difficulty. She otherwise felt well, denying any orthopnea or paroxysmal nocturnal dyspnea. She denied having coughs, sputum, wheezing or chest pain.
She does not remember any important medical problems in her past except about six months ago she had a slight shortness of breath when doing heavy work, she went to an urgent care clinic where she was told that she had asthma, was given inhalers and was advised to quit smoking.
She feels lucky that in her past, whatever medical problems she had, they used to go away by themselves after a few days without needing a doctor’s attention. She vaguely remembers some cold and flu syndromes especially in her childhood that her mother who brought her up singlehandedly, did not consider important enough to seek medical attention. She also remembers that during her childhood there was a time when she had a strange pain and swelling in her knee that went away after a day and then her shoulder became painful. Nevertheless, she did not see a doctor because after a few days everything went back to normal. She also remembers with some regret that there was a time during her teenage years when she was scolded a lot by her hard working mother for sloppiness and dropping the wine glasses and other objects when washing them in the kitchen, but she was happy that she could learn how to keep a stronger grip on the objects that she held in her hands.
Her family history is positive for hypertension in her father and asthma and breast cancer in her mother. Apart from her shortness of breath she has been in good health and has had no surgeries.
Jessica is not married and has no children. She has had several partners in the past and lives with her current boyfriend. She has been a smoker since she was in high school but she feels that the time has come to quit smoking to keep healthy. She drinks one or two glasses of wine and sometimes hard liquor a few times a week. She uses “weed” a few times a month and has tried cocaine once which made her heart race so bad that she thought she was going to die.
Physical examination reveals:
General - a thin woman in no acute distress.
Vitals - her blood pressure is 125/75. Her pulse is 96 per minute, respirations 20 per minute, and her temperature is 37.1ºC. Her oxygen saturation is 93 percent on room air. HEENT - jugular venous pressure of 8, no carotid bruits, no thyromegaly and no cervical adenopathy. Examination of the pharynx is unremarkable.
Lungs – Mild wheezing bilateray.
Cardiac – irregular rhythm, hyperdynamic left ventricular impulse which is displaced laterally, left parasternal lift, soft first heart sound and widely split second heart sound. An apical pansystolic blowing murmur radiating to the axilla is heard which becomes louder with Valsalva maneuver.
Abdomen - soft, non-tender, no ascites, her liver is not enlarged or tender and no organomegaly is appreciated. + Bowel sounds.
Extremities – No ankle edema. Her peripheral pulses are intact.
Neurologic - examination is within normal limits
Skin - no skin rashes.
ECG shows small irregular baseline undulations with different amplitudes with irregularly irregular ventricular response indicating atrial fibrillation and signs of left ventricular hypertrophy. Chest X-ray shows enlarged left atrium and left ventricle plus pulmonary venous congestion.
Blood test reveals:
LFTs and urinalysis are normal
A preliminary diagnosis of mitral valve regurgitation is established but the cause is unknown. The patient is treated with amiodarone 100 mg po,qd, furosemide 40 mg po qd and echocardiography is ordered.
Echocardiography is performed and demonstrates enlarged left ventricle and left atrium with hyperdynamic left ventricular motion due to left ventricular volume overload. Pathological moderate mitral regurgitation, anterior mitral valve leaflet (AMVL) thickening of 5 mm, chordal thickening, restricted leaflet motion, and excessive leaflet tip motion during systole indicate rheumatic mitral valve disease. Ejection fraction is 48%.
These findings established the diagnosis of rheumatic heart disease as the cause of mitral valve regurgitation. Surgical consultation seemed warranted as patient was symptomatic, and reduced ejection fraction indicated left ventricular dysfunction. The surgical team decides that mitral valve repair should be more appropriate for Jessica than mitral valve replacement as it has a lower rate of mortality associated with surgery and a better late outcome than replacement. Jessica is told that mitral valve repair would also prevent the chance of prosthetic valve failure and with properly timed surgery she would be given a postoperative survival rate equal to that of the general population. When Jessica asked if she could be treated with medicines instead of surgery, it was explained to her that currently no non surgical treatment was available for her condition with proven effective outcome, other than prophylaxis against endocarditis.
Five days after surgery, Jessica goes home, breathing has returned to almost normal, and she feels no numbness in hands or legs. The surgical scar in her chest over the sternal area still hurts but the wound is healing nicely. She returns to almost normal activity over the next few months and by four months post discharge she feels great, but has some problems going up the stairs. She is happy with her breathing but complains that her legs get tired when climbing the stairs. She is advised to have cardiac rehabilitation.
During her stay at the hospital, it was explained to her that her problems had been due to heart failure resulting from mitral regurgitation caused by mitral valve damage because of undiagnosed and untreated rheumatic fever in her childhood.
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