Dr RJM Friday Classes Case Discussion 18th February 2022 – Transcript

00:08hello students hello am i audible to you what shall we do today shall i

00:34anybody who is having a case or then i will i have brought a case and we can discuss that case volunteers to discuss the case would you like to discuss do you like to discuss

01:02any volunteers bishnoy would you like to discuss i think you should uh come out we are ready to discuss because morning by repeatedly discussing you will gain the confidence to face the example

01:27eggnog would you like to discuss the case okay there is nobody i think i can ask saroj to do it because she will be always ready to discuss the case would you like to discuss

02:02shall we start then yes sir okay okay now let's start

02:32yes year old female housewife complaining of exceptional business for last 24 years irregular tech transportation for last 12 years swelling of both the legs for last 12 years okay based on the initial symptoms what is your thought process

03:04that she is a 52 year old female businessman 24 years long spending breathlessness okay so she is symptomatic from the age of 28 yes okay so what are the possibilities in your mind

03:42yes sir at the age of 28 if she had started surprised i will think of a regular heart disease possibly rheumatic or even regurgitant type of lesion long standing history rheumatic heart disease you need not go for the regular nation you can consider them as stenotic also but um at the most mild or low moderate issue

04:08it's not a it's not a severe lesion and the progression of the disease process also is very slow so that would be the way in which you can discuss i agree with you that my regulatory lesions take longer time for deterioration while stenotic relations can deteriorate faster so of the two nations you can give importance to regulation but the most important point you have to stress is that most likely

04:33only relations are mine or low moderate okay then what happened yes sir so something has gone wrong with my this thing so just one minute something has gone wrong with your what

04:58yes sir sir i could not see the screens it is visible sir okay history of present illness no no no uh sorry uh possibly this is atrial fibrillation a patient with romantic heart disease which while the norman gives rise to a

05:25mighty value involvement micro and environment so regular palpitation which is most likely atrial fibrillation you can start thinking that the patient might have might be having mitral disease and that is the cause for atrial fibrillation okay biotin environment is less likely to give rise to atrial fibrillation okay then intermittent feeling of both the legs sorry it means that

05:49patient has gone into right heart failure okay the most uh indicates that probably the patient has got some degree of right heart involvement resulting in systemic congestion and swelling of both the legs now what are the possibilities yes hello hello and what are the

06:16possibilities for for you to discuss infamous and swelling of both the legs giving rise to the right heart uh systemic congestion which is right heart failure what may be the pathogenesis so most probably the patient has got a suddenly going for trichosphere regulation uh you said that there is

06:42some vital disease yes sir so patient has developed the pulmonary venous hypertension denser pulmonary artery hypertension cancer backward sorry failure answer then it's a systemic condition okay the patient might have permanent venous congestion permanently hypertension and that might have

07:09resulted in the stress on the right ventricle right ventricular uh that can result in psychospherical degradation all these features might have contributed to the element of incremental swelling of the both the legs okay so if the patient has done a permanent arterial hypertension then what is the more likely lesion is a regulation

07:45hypertension quite late while mitosis gnosis can give rise to permanent hypertension quite early in the in the natural history of the disease process why it is so so because in case of mitral regurgitation the la compliance is high as a result it will take more time for the pulmonary venous hypertension to develop no that's not the reason

08:14no compliance is applicable to both as well as regular issues if the la is not compliant then both in stenotic as well as regulations pressure can quickly go up that can result in permanent venous congestion but in patients with mitral stenosis and mitral regurgitation aromatic ethiology there is sufficient time for the the left atrium to become compliant can increase in size and hence

08:41the compliance of the right atrium left atrium of course it may be restricted but it is applicable to both mitral regurgitation as well as mitosis equally what is the difference in the earlier pressure in patients with mitosis and micro regurgitation that's the point you should know yes sir in case of left mitral stellosis left atrial pressure is

09:08high higher than the left that in the micro regurgitation not completely correct you have why this high that's supposed to

09:36any one of you any any of the participants would you like to give a comment in what phase of cardio cycle does the pressure and the left side thing goes up in micro regurgitation in what phase of cardio cycle does the

10:03pressure in the left hip ring go up in mitral regurgitation during systole during system you know what happens in diastole so in diastole it will decrease decrease because the mitral value is not obstructed mental opens out completely and that will result in emptying of the left atrium the left hand again left here pressure comes down what happens in mitral stenosis

10:33left actual pressure is higher in diastole in vital stenosis that is not correct it can be high in systole also because when the blood comes into the left when left in the pressure is higher in diastole forces stored normally the pressure is hit higher during

10:58diastole

11:26see what is happening during uh when the cross is stored to the atrium what is happening to the uh to the blood flow to the atrium

11:54what happens to the atrium during diastole atrium empties into diastole into left ventricle and this corresponding ventricle and the pressure comes down so entropy is higher during uh when the process is stored than ventricular diastole normally and muscle regurgitation is significantly higher because of the regulation what is the difference in the left

12:21represent mitral stenosis and vital regulation that is what i want to know hemodynamically any one of you you know it will be high both in a sisterly and isolation yeah that's the most important one the electrical pressure will be uniformly elevated in systole as well as the store meaning uh there is a mean left

12:48represents a significant mean level to pressure elevation in microstenosis while in a position with the vital regurgitation the left hand pressure is elevated during systole significantly elevated but immediately the following is stored when there is a diastole the whole left pressure comes down because of the emptying of the left atrium in the left ventricle because of that the um the permanent wheels pressure does not significantly rise in microwave in

13:15rigorous deletions but it significantly rises in steroid lesions and hence the permanent hypertension occurs quite early in mitral stenosis and it occurs very late in mitral regurgitation when does the permanent hypertension develop in micro regurgitation

13:46potential but in patients with the vital synosis when the when there is an obstruction to the flow of blood from the left atrium to the left to underground that will result in uniform elevation of the depth of pressure that will certain permanent congestion and dysfunction also will affect similarly the if always three dysfunction in like in hypertension occurs that will affect in case of mitral degradation to develop