Mitral stenosis, progressive dyspnea on exertion,
nonspecific for any valvular heart disease.
Hemotypsis, why? Why we are seeing this more
so than any other valvular heart disease?
It is the fact that the left atrium is not
emptying. It back up to your pulmonary veins
hence resulting in. Could you have increased
RBCs in your lungs and such? Sure. Coughing
up of blood, that is not good. Heart failure,
late finding, once again a bad prognosis. It
means what? Well the opening snap, we
talked about how it will be after S2 called
it as mid-diastolic murmur. The closer
that your opening snap is to S2, the worse
is the prognosis. Tell me the size of your
left ventricle. Very very tiny. Eventually,
what is going to happen? It become the pulmonary
edema? Sure. We will talk about that increased
hydrostatic pressure. Right? Then you have what?
It may transmit this disease into the right
ventricle. Might have right ventricular failure.
Is this, very important question pay attention,
is this cor pulmonale? Nope. "But Dr. Raj, right ventricular
failure secondary to left-sided heart failure?"
Yes. That is not cor pulmonale? No. So what
is cor pulmonale? It is right ventricular
failure secondary to a primary pulmonary disease
such as maybe pneumonia, maybe pulmonary fibrosis
so on and so forth. But when you have right
ventricular failure here due to left-sided
heart failure, that's not cor pulmonale. But
if you do find it, mitral stenosis, not a
good prognosis. Physical examination. Palpation,
heave. What does that mean? It means pulmonary
hypertension. What about the PMI? Pay attention
here. What is PMI? Point of maximal impulse.
So I don't know that means. Ya you do. PMI is the apex
of the heart and where is the apex? What chamber
is that when you refer to the apex? Left ventricle.
What is the size of your left ventricle? Either
normal or maybe decreased. It is never cardiomegaly.
It makes no sense. The left ventricle
is not going to go laterally displaced. Is
that clear? Every single statement that we
have here has huge clinical relevance.
I have information that goes outside of the apparent
slide and such, but it is only so that we
have a complete story, so that we have more
differentials, so that we integrate more material.
All this information at some point in time,
is touched, will be touched, and forever will
be part of your understanding. Mid-diastolic
murmur is what we talked about occurs during
diastole. Heard loudest well, we talked about
this where, when it comes to mitral issues.
Where am I? Where are you upon cardiac auscultation?
No issues between S1, S2.
So that will be wholly systolic.
It is after S2, you have an opening snap and
then you have it. It is after S2. It
is after that "dadup". You are going to hear
an opening snap, where you can hear this? Auscultation,
fifth intercostal space, midclavicucular,
apex is where you are. What kind of murmur?
A mid-diastolic murmur. Afib is something
that you want to worry about. What does afib mean to you?
It means that you are going
to mess up your conduction system. And with
atrial fibrillation what might you be
looking for? What wave? Are you paying attention?
You tell me. Atria. If you say QRS complex,
I will find a way to come there and slap you.
No. But the P wave is what you are paying
attention to, atria. What is the wrong with
those P waves? They are not present, are they
wavy? Not saw-tooth. That's atrial flutter.
That is another discussion for another day.
Atrial fibrillation is wavy P waves. You don't
have them. Now, what are you worried about
afib, please? Well you have heard of Virchow's
triad, haven't you? Not Virchow's node, Virchow's
triad. A direct triangle there because it
is three different points. One point would
be endothelial injury, is that what this is? No.
Number 2 hypercoagulability, is that what this is? No.
Number 3, turbulent, blood
flow stasis. This is turbulence. So what does
Virchow triad mean to you? The development
of what? A thrombus. And so therefore if a patient
has afib, aren't you prone to thrombi? Absolutely.
And as soon as you hear afib, what are you
putting this patient on immediately as prophylaxis?
Prophylaxis for what? Atrial fibrillation, a form of trauma.
Then what? And then you break it off. You break
off am emboli, where does it go? It goes maybe
up in the carotid. That is the most devastating
manifestation. Going up into the carotid resulting
in a cerebrovascular accident. Why would you
want a stroke? Prevent it from happening. The
drug by research shown to be the best for
prophylaxis of thrombi formation afib is
going to be warfarin. Wage war against the
thrombi for prophylaxis in atrial fibrillation.
Let us continue.