14. Mitral valve prolapse

Swelling, protrusion of one or both cusps of the mitral valve into the cavity of the left atrium during ventricular systole.

CAUSES:

1. primary (congenital) is associated with microsomal degeneration of the fibrillar structures of the valves and / or tendon chords, often combined with defects in connective tissue structures (Marfan syndrome, flat feet, hernias, curvature of the spine, etc .;

2. secondary: develops against the background of heart lesions in coronary heart disease, hypertrophic cardiomyopathy, carditis of another etiology;

1. Complaints of pain in the region of the heart, especially during excitement, are not associated with physical exertion, are not removed by nitroglycerin, are inconsistent, heart failure, palpitations;

2. Auscultation: at the apex, a systolic click or late systolic murmur (or a combination of both) is determined. They increase vertically and decrease horizontally.

3. ECG: reduction or inversion of T waves, a slight decrease in the S-T segment in II, III, less often in V5 and V6 leads;

4. FCG: late systolic murmur, late systolic click;

5. Echocardiography: deflection of one, sometimes both cusps of the mitral valve in the late phase of systole into the cavity of the left atrium;

6. Doppler echocardiography: mitral regurgitation;

15. Syndrome of hypertension of the pulmonary circulation

CAUSES:

1. primary - 0.2% of all cases, etiology is unknown

2. secondary - mitral heart defects, left ventricular heart failure, some congenital heart defects with blood discharge from left to right, pulmonary thromboembolism, acute and chronic lung diseases, hypoventilation, high-altitude hypoxia, Ayers syndrome (A. Ayezza) (pulmonary sclerosis) .

SYMPTOMS:

1) shortness of breath, passing into suffocation (BH>20¢)

2) cyanosis (acrocyanosis or diffuse)

3) cough (dry or with sputum)

4) hemoptysis

5) dizziness and fainting

6) pain in the heart due to hypertrophy of the myocardium

7) angiospasm (e.g. Raynaud's syndrome)

8) possible tachycardia (heart rate > 80¢)

9) signs of right ventricular failure (see the corresponding section)

10) hypertrophy of the right ventricle (percussion, ECG, ECHO)

11) emphasis II tone over the pulmonary artery

12) wheezing (dry and wet), crepitus in the lungs

13) on the ECG - ―P‖ - high, expanded in II and III leads, hypertrophy of the right ventricle and left atrium

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14. on the phonocardiogram - emphasis and splitting of II tone on the pulmonary artery

14. R - graph of the lungs: root compaction, thickening of the vascular pattern, cloud-like shadows, a small effusion in the pleural cavities, an increase in the right ventricle of the heart

14. VC is reduced

14. ECHOCG: increased pressure in the pulmonary artery, its dilatation, hypertrophy of the right heart.

16. The syndrome of acute vascular insufficiency

A. syncope (syncope) - a short-term, mild form of acute arterial hypotension

REASONS: acute cerebral anemia due to a mental or reflex effect on the circulatory regulation system. There are vasovagal syncope, orthostatic, sinocarotid, psychogenic, symptomatic. STAGES:

• forerunners

• impaired consciousness

• recovery period

SYMPTOMS:

1) weakness

2) dizziness

3) ringing in the ears,

4) short-term visual impairment (veil, darkening, "flies" before the eyes)

5) pallor of the skin and mucous membranes

6) instability of the pulse, respiration and blood pressure (tachycardia, filamentous pulse, drop in blood pressure)

7) hyperhidrosis

8) decrease in muscle tone

9) short-term impaired consciousness

10) pupils dilated, slow response to light

11) patient may fall

12) short-term convulsions of a tonic, less often clonic nature

B. COLLAPSA Severe form of vascular insufficiency (a more pronounced and prolonged drop in vascular tone, leading to a violation of the vital functions of the body).

REASONS: infectious, toxic, hemorrhagic, hypoxic, orthostatic, cardiogenic, hypovolemic, sympatho-vagotonic, paralytic collapses.

SYMPTOMS:

1) consciousness is often preserved, patient indifference to the environment, lethargy, adynamia

2) dizziness

3) visual impairment, dilated pupils

4) tinnitus

5) thirst

6) chills at low body temperature

7) pointed features

8) sharp pallor with acrocyanosis

9) cold sweat

10) cold limbs

11) the pulse is frequent, small

12) venous pressure and blood pressure sharply reduced, cervical veins collapsed

13) heart sounds are deaf, arrhythmias, embryocardia are possible

14) shallow breathing (rapid or slow)

15) shock development is possible

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Shock (from the English shock - shock, shock) is an integral pathological process that develops in response to extreme stimuli and is accompanied by a progressive violation of the vital functions of the nervous system, blood circulation, respiration, metabolism and some other functions. This is a failure of the compensatory reactions of the body in response to damage.

The clinical picture depends on the type of shock (cardiogenic, anaphylactic, infectious-toxic, post-traumatic, hypovolemic), which develops against the background of progressive vascular insufficiency.

3.1 TEST TASKS

(Choose one or more correct answers)

1. Pulsation of the carotid arteries ("dance carotid") is observed when

   1. stenosis of the mouth of the aorta

2. aortic valve insufficiency

2. With increasing pressure in the pulmonary artery will be observed

   1. attenuation of II tone on the pulmonary artery

2. emphasis II tone on the pulmonary artery

3. emphasis and II tone on the aorta

3. The emphasis of the II tone on the aorta is

   1. II tone on the aorta is louder than I tone

2. II tone on the aorta is louder than II tone on the pulmonary artery

4. Indicate the most characteristic signs of arterial pulse in atrial fibrillation.

   1. a sharp weakening or lack of pulsation on one radial artery

2. a sharp decrease in the pulse value on both radial arteries

3. the number of pulse waves in the radial artery is greater than the number of heart contractions

4. the number of pulse waves in the radial artery is less than the number of heart contractions

5. The main method for identifying endocardial syndrome

   1. ECG

   2. FCG

3. ECHO-KS

6. For stenosis of the mitral valve is characteristic

1. the rhythm of the "quail"

2. protodiastolic gallop rhythm

7. What defect is the symptom of Alfred de Musset

   1. aortic stenosis

2. aortic insufficiency

3. mitral stenosis

4. mitral insufficiency

8. When auscultation in a patient with mitral valve insufficiency is detected

   1. attenuation of the second tone and systolic murmur on the aorta

2. attenuation of the first tone and systolic murmur at the apex

3. clapping first tone, diastolic murmur at the apex

4. attenuation of the second tone and diastolic murmur on the aorta

9 Symptom characteristic of the appearance of a patient with stenosis of the aortic orifice

1. diffuse cyanosis of the skin

2. acrocyanosis

3. pallor of the skin

4. symptom of Musssi

5. Carotid dance

10. How to change the pulse pressure with stenosis of the mouth of the aorta

    1. does not change

    2. increases

3. more often decreases

3.2 Tasks for the section “Cardiovascular system”

Task 1

Patient S., 62 years old, complained of pressing pains behind the sternum and in the region of the heart that arise after psycho-emotional and physical exertion, radiating to the left arm, shoulder blade, accompanied by a sense of fear of death, stopping at rest or when taking nitroglycerin after 2 minutes.

From the medical history of the disease, it is known that an increase in blood pressure is noted over 15 years (maximum figures are 200 and 120 mmHg, adapted to 130 and 80 mmHg). For the last 2 years after psychoemotional and physical overloads, pressing pains behind the sternum occur, stopping with nitroglycerin after 2-5 minutes. From the anamnesis it is known that the patient smokes for 20 years at 18-20 cigarettes per day.

When examining a patient of increased nutrition. For centuries, xanthelasma. Percussion borders of the heart are shifted to the left. The cardiac sounds at the apex are weakened, the emphasis is II tone above the aorta. HELL 180 and 100 mmHg, heart rate-78ud. in minutes

1. Manifestations of what syndromes can be noted in a patient?

2. What are the risk factors for developing coronary heart disease in this particular case?

Task 2

Patient M., 54 years old, was taken by an emergency medical team to the intensive care unit complaining of intolerable burning pains behind the sternum, accompanied by severe weakness, cold sweat, and a feeling of lack of air. Taking nitroglycerin did not stop the pain.

Today, after physical work (lifting weights), for the first time in my life, intolerable stinging, burning pains behind the sternum appeared, radiating to the interscapular space accompanied by a sharp weakness, cold sweat. The pain was not stopped by taking 3 tablets of nitroglycerin. The total duration of the attack is 1 hour.

On examination: the patient is sitting. The skin is pale, cyanotic, covered with large drops of sweat. Bubbling breathing with the release of copious frothy pink sputum. Weakened vesicular breathing, a large number of moist, various-sized, sonic rales are heard over the lungs. Chd-26 in a minute. Heart sounds are sharply weakened, the protodiastolic gallop rhythm is heard. AD-95 and 50 mmHg Heart rate-110 per minute. The pulse on the peripheral arteries is small, filiform.

On the ECG - in leads V1-6, I and AVL, a complex of type QS, ST segment elevation of more than 5 mm (trough-shaped), negative coronary tooth T.

1. What syndromes can be distinguished on the basis of this clinical picture?

2. What disease can be thought of on the basis of this clinical picture?

Task 3

Patient V., 65 years old, came to the clinic with complaints of bursting pain in the epigastric region, accompanied by nausea, vomiting once ..

He became acutely ill: after work (associated with significant physical exertion) there were pains in the epigastric region, nausea. At night, the intensity of pain in the epigastrium intensified, they radiated beyond the sternum, into the left shoulder blade, were accompanied by nausea, vomiting once, cold sweat, fear of death. After the use of narcotic analgesics by the ambulance team, the pain practically disappeared.

On examination, the state of moderate severity. The skin is pale, high humidity. Vesicular breathing over the lungs, wheezing is not heard. Heart sounds are weakened, a gallop rhythm is heard at the top. Heart rate-115 per min. HELL 105 and 70 mm Hg The abdomen is painless on palpation. There are no symptoms of peritoneum. On the ECG, a pathological Q wave in lead III, AVF, ST segment elevation in II, III, AVF leads.

1. What is the leading syndrome in this clinical picture?

2. What localization of myocardial damage can we talk about in this case?

Task 4

Patient M., 36 years old, was admitted with complaints of shortness of breath with small physical exertion, cough with sputum mucus, swelling of the legs, heaviness in the right hypochondrium.

In childhood, there was an episode of prolonged fever with swelling of the knee and ankle joints. It was treated on an outpatient basis, and subsequently was not observed by doctors.

During the examination: in the lungs, on both sides in the lower sections, moist, sonic, finely bubbling rales. The

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pulse is 100 beats per minute, rhythmic. With auscultation of the heart - at the apex of I, the tone is weakened, systolic murmur of a diminishing nature, conducted in the left axillary region, emphasis of II tone on the pulmonary artery. The enlarged liver is palpated. Pastosity of the legs.

1. Symptoms of which valvular heart disease are present in this patient? Justify.

2. What data can be obtained by palpation and percussion of the heart?

3. What clinical syndromes can be distinguished?

Task 5

Patient D. was admitted to the clinic with complaints of severe general weakness, fatigue, shortness of breath, fever up to 39 ° C, chilling, profuse sweating.

Sick for a month. From the age of 14 he suffers from rheumatic mitral heart disease. On examination: the skin and visible mucous membranes are pale with a yellowish-gray tint (―coffee with milk‖). On the conjunctiva and transitional folds of the eyelids of hemorrhage (Lukin-Liebmann symptom), a positive symptom of Rumpel-Leede-Konchalovsky. Fingers look like drum sticks. With auscultation of the heart: at the apex of I, the tone is weakened, systolic murmur conducted in the left axillary region; in the 2nd intercostal space to the right of the sternum, a weakening of the II tone; at the point of Botkin-Erba there is a soft blowing diastolic murmur of a decreasing character. When examining the abdomen, an increase in the spleen is determined.

1. What valvular lesions of the heart is evidenced by an auscultatory picture?

2. What data can be obtained during palpation and percussion of the heart region with detected defects?

3. What clinical syndromes can be distinguished?

4. What disease are these syndromes characteristic of?

Task 6

Patient S., 36 years old, was admitted to the hospital with complaints of shortness of breath during physical exertion, nightly attacks of suffocation, dizziness.

He does not remember the diseases transferred in childhood. Dyspnea, dizziness during physical exertion worries for a year, in the last month attacks of inspiratory suffocation joined.

On examination: the skin is pale, ―dance carotid‖, a symptom of Musset, a symptom of Quincke. In the 6th intercostal space along the anterior axillary line, a reinforced ―dome-shaped‖ apical impulse is palpated on the left. During auscultation, the I tone at the apex is weakened, above the aorta the weakening of the II tone, protodiastolic murmur in the II intercostal space and at the point of Botkin-Erba.

1. Symptoms of what heart damage does this patient have?

2. What does the symptoms identified during the examination mean and what are their causes?

3. What kind of pulse and blood pressure can be expected in this patient?

Task 7

Big R., 28 years old, was admitted to the clinic for examination with complaints of rapid fatigue, shortness of breath, discomfort in the heart during physical exertion, dizziness. In childhood - private tonsillitis, tonsillectomy at 10 years old.

On examination: the skin is pale. During auscultation of the heart - weakening of the I tone at the apex, weakening of the II tone above the aorta, a rough systolic murmur, of increasing-decreasing nature, in the second intercostal space to the right of the sternum, carried out on the carotid arteries. Pulse - 64 beats. in minutes, blood pressure - 95 and 60 mm Hg

1. What valve damage to the heart can be thought of, given the auscultation of symptoms?

2. What data can be obtained by palpation and percussion of the heart region with this defect?

3. Describe the features of the pulse with this defect.

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Patient V., 21 years old, was admitted to the hospital with complaints of shortness of breath with small physical exertion, hemoptysis.

In childhood - frequent sore throats, at the age of 7 after the next sore throat large joints swelled and hurt. Shortness of breath has been bothering for the past 6 months, gradually intensifying, a month ago hemoptysis first appeared. On examination: moderate lip cyanosis, no peripheral edema. The number of respiratory movements at rest is 24 per minute, in the lower parts of the lungs are moist, inexplicable, small-bubbling rales. The apical impulse is not visible and not palpable. In the apex region, diastolic trembling is determined. The boundaries of the relative dullness of the heart: the right - 2 cm outwards from the right edge of the sternum, the left - 1.5 cm inwards from the left midclavicular line, the upper - the second intercostal space. Pulsus differens, worse left.

1. What valve damage to the heart can you think of? Justify.

2. What should be the auscultatory picture of the heart with this defect?

3. What is the cause of Pulsus differens?

4. What symptoms indicate the presence of congestion in the pulmonary circulation?

Task 9

Patient A., 32 years old, was admitted with complaints of shortness of breath at the slightest physical exertion, swelling of the legs, feet, heaviness in the right hypochondrium, an increase in the volume of the abdomen.

In childhood - frequent sore throats, at 12 years old, mitral heart disease was diagnosed. From 16 years old, shortness of breath worries, from 28 years old - swelling of the legs appeared in the evening, heaviness in the right hypochondrium. Repeatedly treated in a hospital. Over the past 4 months, there has been an increase in shortness of breath, swelling, the appearance of dull pain in the right hypochondrium, an increase in the volume of the abdomen.

On examination: serious condition. Orthopnea position. Acrocyanosis, ―facies mutrale‖, swelling and pulsation of the veins of the neck, swelling of the feet, legs. The number of breaths is 26 per minute. In the lower parts of the lungs moist finely bubbly inaccurate rales are heard. During auscultation of the heart - at the top of I the tone is loud, ―clapping‖, the tone of the opening of the mitral valve followed by diastolic murmur, the emphasis of the 2nd tone on the pulmonary artery, systolic murmur at the base of the xiphoid process, amplified by inspiration (Rivero-Corvallo symptom). The abdomen is enlarged in volume, an enlarged liver, ascites are determined.

1. What syndromes can be distinguished? Task 10

Patient A., aged 16, was admitted to the clinic with complaints of shortness of breath, palpitations, febrile temperature, pain in large joints, and pains disappearing in some joints and appear in others. She became ill acutely after suffering a sore throat 2 weeks ago.

On examination: moderate condition. The skin is of high humidity. On the skin of the chest and abdomen - rashes in the form of pale pink rings, painless, not rising above the skin. The right knee and left shoulder joints are swollen, the skin above them is hot and touch, hyperemic, active and passive movements in them are sharply limited. With percussion of the heart - the shift of the boundaries of the relative dullness of the heart to the left by 1.5 cm outwards from lin. Mediaclavicularis sin. With auscultation of the heart, weakening of the I tone and soft systolic murmur at the apex are noted, the number of heart contractions is 110 per minute. The pulse is rhythmic, weak filling. HELL - 100 and 60 mm Hg

In blood tests: leukocytes - 15 x 109 l, ESR - 42 mm / hour, positive C-reactive protein, anti-O-streptolysin titers more than 500 units (normal - less than 250 units). ECG - sinus rhythm, PQ-0, 24 sec

1. What organs are affected by the symptoms identified?

2. What disease can be thought of on the basis of the identified symptoms? Justify.

3. How can one explain the appearance of soft systolic murmur at the apex?

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Answers to the tasks to the section

"The cardiovascular system"

Task 1

1. The patient has signs of angina pectoris (angina pectoris) and arterial hypertension syndrome.

2. Arterial hypertension, smoking. Given the excess body weight, the presence of xanthelasm, it is also necessary to study the lipid spectrum of the blood.

Task 2

1. Syndrome of acute coronary insufficiency, syndrome of acute left ventricular failure (pulmonary edema).

2. You can think about the presence of a common anterior myocardial infarction.

Task 3

1. In this case, the leading syndrome is the syndrome of acute coronary insufficiency

2. This patient has a myocardial infarction of the posterior wall of the left ventricle.

Task 4

1. Mitral valve insufficiency: weakening of the I tone at the apex, systolic murmur of a decreasing nature, conducted in the left axillary region.

2. Spilled reinforced apical impulse, displacement of the borders of the relative dullness of the heart up and to the left, mitral configuration of the heart.

3. a) Right ventricular failure syndrome (enlarged liver, swelling of the legs).

2. Syndrome of left ventricular failure (shortness of breath, cough with sputum mucosa, moist, sonorous rales in the lungs)

Task 5

1. Mitral and aortic valve insufficiency.

2. On palpation - reinforced spilled apical impulse, shifted to the left and down. With percussion, the shift of the boundaries of the relative dullness of the heart up, left and down.

3. a) Inflammation syndrome

b) hemorrhagic

4. Infectious endocarditis.

Task 6

1. Symptoms of aortic valve insufficiency.

2. Pulsation of the carotid arteries, rhythmic shaking of the head, pseudocapillary pulse - due to high systolic and low diastolic blood pressure (high pulse pressure)

3. The pulse is high, fast and large (altus, celler, magnus). High systolic blood pressure, low diastolic blood pressure, large pulse blood pressure.

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Task 7

1. Stenosis of the mouth of the aorta.

2. Systolic trembling in the second intercostal space to the right of the sternum; high, reinforced, diffuse apical impulse, shifted to the left. With percussion, a shift of the left border of the relative dullness of the heart to the left; aortic configuration of the heart.

3. The pulse is small, slow, rare (parvus, tardus, rarus)

Task 8

1. Stenosis of the left atrioventricular orifice: diastolic tremor at the apex of the heart, shift of the borders of the relative dullness of the heart up and to the right, pulsus differens.

2. At the top there is a loud ―popping‖ I tone, an additional tone for opening the mitral valve, ―quail rhythm‖, diastolic murmur with presystolic amplification; accent II tone over the pulmonary artery.

3. Significant increase in left atrium leading to compression a. subsclavia sin.

4. Shortness of breath (tachypnea), moist sonorous rales in the lungs, hemoptysis.

Task 9

1. a) Syndrome of left ventricular failure (dyspnea, tachypnea, orthopnea, moist sonorous rales in the lungs).

2. The syndrome of right ventricular failure (acrocyanosis, swelling and throbbing of the veins of the neck, edema, hepatomegaly, ascites).

Task 10

1. a) Joint damage (arthralgia, joint changes during examination)

b) Heart damage (weakening of the I tone, systolic murmur, atrioventricular block I degree)

2. Rheumatic polyarthritis, rheumatic heart disease:

1. The onset of the disease 2 weeks after a streptococcal infection;

2. Ring-shaped erythema;

3. Typical damage to large joints and ―volatility‖ of arthralgia;

4. Rheumatic heart disease - tachycardia, weakening of I tone, systolic murmur at the apex, atrioventricular block of I degree;

6. Blood tests - lecocytosis, accelerated ESR, positive CRP, increased titers of anti-O-streptolysin.

3. The development of relative mitral valve insufficiency.