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A 32yr old patient Mr. Nagaraj was admitted with c/o breathlessness and palpitation for 20 days
H/O PND +
H/O palpitation for past 20 days
-persistent
No H/O chest pain, syncope, fatiguability No H/O fever, cough with expectoration No H/O pedal edema, facial puffiness,
PAST HISTORY
FAMILY HISTORY
Married, had two children
PERSONAL HISTORY
Not a smoker/alcoholic
GENERAL EXAMINATION
O/E
Pt conscious, oriented, afebrile, mild pallor& mild pedal edema present JVP elevated
VITALS
PULSE
Rate- 98/min
regular in rhythm, large volume, collapsing pulse, felt in all peripheral vessels , no radio-radial delay/radio-femoral delay
SYSTEMIC EXAMINATION
INSPECTION
Hyperdynamic apical impulse seen in Left 6TH
PALPATION
Parasternal heave - grade-II
Apical Impulse in left 6th ICS 2cm lateral to MCL
intercostal space
Palpable p2
AUSCULTATION
LEFT 3RD AND 4TH ICS
S1, S2 heard
PULMONARY AREA
P2 loud
OTHER SYSTEMS
RS- NVBS heard, no added sounds
P/A- soft, no organomegaly CNS- NO FND
PROBLEMS
Dancing carotids, locomotor brachii, uvular
pulsations, pistol shot sign,large volume collapsing pulse signs of aortic run off
Loud superficial continuous murmur with
D/Ds
RUPTURE OF SINUS OF VALSALVA ANEURYSM
CORONARY AV FISTULA PDA AP WINDOW ALCAPA
INVESTIGATIONS
CBC - HB -11gms
TC 7600
DC P68%, L31% PLATELET-1,50,000
ECG
ECG
ECG
CHEST X-RAY
IMPRESSION
CARDIOMEGALY
ECG FINDINGS
NSR,
HR- 100/min AXIS -30 LAE/LVH
ECHOCARDIOGRAPHY
ECHO FINDINGS
TTE
LV IDd 59mm LV IDs - 39mm LV EF - 62% DILATED LA/LV JERKY FLAT IVS
IMPRESSION
PROBABLE RUPTURE OF RIGHT CORONARY SINUS
TEE
DILATED LA/LV JERKY IVS
RVOT
RVOT GRAD- 45 OTHER CHAMBERS AND VALVES NORMAL NO E/O VEGETATIONS AND SHUNTS
IMPRESSION
RUPTURED RIGHT SINUS OF VALSALVA ANEURYSM INTO RVOT
Sinus of valsalva
FINAL DIAGNOSIS
RUPTURED RIGHT SINUS OF VALSALVA ANEURYSM INTO RIGHT VENTRICLE
TREATMENT
NASAL O2 6L/min
BED REST/BACK REST SALT & FLUID RESTRICTION T. ENALAPRIL 2.5mg 1 BD T. FRUSEMIDE 20mg 1 BD PT REFERRED TO HIGHER CENTRE FOR SURGICAL
CORRECTION
COA, Bicuspid Aortic valve. Any case with dyspnoea in the presence of continuous murmur may be due to ruputure of sinus of vasalva. Many of the cardiac diseases with heart failure can be treated with only medical management. But a definitive surgical cure is possible only in such cases.