internal medicine
الطب بطريقه سهله ...... حالات ، أسئلة شفوي Long case Short case Osce ECG Step by step Start by Blood End by rheum
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🧑🏼⚕A. Because:
✓ Systolic thrill in mitral area
✓ First heart sound is soft
✓ There is a PSM radiating to the left axilla.
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🧑🏼⚕ My diagnosis is chronic rheumatic heart disease with mitral regurgitation.
Cardiovascular system
⭕ Pulse: 88/min, normal in volume, rhythm and character
⭕ JVP: not engorged
⭕ Blood pressure: 130/85 mm Hg.
Precordium
Inspection:
⭕ Visible cardiac impulse in mitral area.
Palpation:
⭕Apex beat: shifted, in the left 6th intercostal space, ... cm from midline, diffuse, thrusting in
character
⭕ Thrill: present in left 6th intercostal space, systolic in nature.
Auscultation:
⭕ 1st heart sound: soft in mitral area, normal in other areas
⭕ 2nd sound: normal in all the areas
⭕ 3rd heart sound: may be present
⭕ There is a pansystolic murmur in mitral area, which radiates to the left axilla (reduced on inspiration
and more on expiration).
Examination of other systems reveals no abnormalities.
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🧑⚕ How are you 😊 for everyone?
🧑⚕ Answer is:
A. Usually, warfarin is given who are at risk of stroke. Target INR is 2 to 3. It reduces stroke in 2/3rd
cases. Aspirin reduces stroke in 1/5th cases. Anticoagulation is indicated in patient with atrial
fibrillation having risk factors for thromboembolism.
🧑⚕Risk factors for thromboembolism in atrial fibrillation:
✓Previous ischaemic stroke or TIA
✓ Mitral valve disease
✓Age over 65 years
✓Hypertension
✓ Diabetes mellitus
✓Heart failure
✓ Echocardiographic evidence of left ventricular dysfunction, left atrial enlargement or mitral anular
calcification.
Risk groups with thromboembolism (nonrheumatic):
✓Very high: Previous stroke or TIA (12%)
✓ High: Age > 65 years and one other risk factor (6.5%)
✓ Moderate: (i) Age > 65 years, no risk factor (4%), (ii) Age < 65 years, other risk factor (4%)
✓ Low: Age < 65 years, no risk factor (1.2%).
🧑⚕also Score as comments you read CHA2DS2-VASc score
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