NON-MURMUR CONDITION QUIZ<br />Dr. S. Aswini Kumar. MD.<br />01. This 35 year-old man, who was a chronic heavy smoker and hypertensive, developed a retrosternal chest pain while climbing the railway over bridge. The pain lasted for about five minutes and disappeared after a period of rest. The pain recurred the next day at the same instance when he climbed the same stairs at the same pace02. This 45 year-old man used to have recurrent retrosternal chest pain while walking about 100 meters. The pain used to be relieved with intake of one tablet of nitrate taken sub-lingually. But since last two months the pain is not relieved by taking rest of nitroglycerine. Not only that, the pain also occurred while he was taking absolute rest03. This 65 year-old woman developed a sudden onset of suffocation in the chest, when he heard the news of the death of his son in a road traffic accident. There was profuse sweating and a feeling of impending death. On examination the patient was having tachycardia and low blood pressure and the heart sounds were muffled.04. This 65 year-old man presented with history of fatigue and giddiness as well as exertional dyspnoea. Clinical examination showed severe anemia, tachycardia with and raised jugular venous pressure. The apex was shifted to the sixth left intercostal space one cm outside MCL. An S3 and S4 summation gallop was heard without a murmur.05. This 55 year-old man presented with acute onset of breathlessness and orthopnea at 2 am. He was a known coronary artery heart disease patient off drugs for some time. There were few episodes of paroxysmal nocturnal dyspnoea in the past. On admission the patient was acutely breathless with LV S3 and bilateral basal crepitations.06. This 65 year-old woman presented with history of breathlessness two months duration. There was history of Acute Anterior wall Myocardial Infarction, six months back. There was moderate cardiomegaly with a visible see-saw pulsation diffuse and dyskinetic apical impulse and. There was an S3 gallop which was heard over the apex. 07. This 55 year-old man presented with palpitations and tremor of fingers of three months duration. Clinical examination showed an irregularly irregular pulse with an apex pulse deficit of twenty eight. Examination of the heart was unrewarding except for the varying intensity of the first heart sound and accompanying heart failure.08. This 45 year-old woman presented with history of giddiness and vertigo of two weeks duration. There was no other relevant past history. Examination showed pulse of 82/minute and BP of 180/110 mm of Hg. Examination of the heart showed a normally placed apex which was heaving in character. A2 was loud and an S4 was also heard.09. This 15 year-old boy was admitted to the hospital with history of fever of high grade of 3 days duration. The child appeared to be very sick. The pulse was 130 per minute and the blood pressure 80 mm of Hg. Examination of the precordium was normal and the heart sounds were muffled. S3 gallop and bilateral basal crepitations heard.10. This 35 year-old woman with CRF presented with precordial dull aching pain aggravated by movements of chest. The most prominent physical finding was a triphasic sound, best heard towards the base of heart, changing in intensity with change in position of the patient. There was no evidence of hypotension or pulsus paradoxus.11. This 45 year-old man with PTB presented with exertional dyspnoea and orthopnoea. He developed progressive abdominal distension and pedal edema. The pulse and BP were normal; but the jugular venous pressure was elevated with an increase during inspiration. There was no cardiomegaly. A pericardial knocking sound was heard 12. This 55 year-old woman had a catching type of chest pain to the left of sternum, which disappeared in 2 days and she then developed progressive dyspnoea at rest. There was low grade fever. The pulse showed tachycardia and pulsus paradoxus. The blood pressure and JV pressure were normal. Heart sounds were muffled and distant.13. This 55 year-old chronic alcoholic person presented with history of gradual onset but steadily progressive exertional dyspnoea and pedal edema. Clinical examination showed narrow pulse pressure and raised jugular venous pressure. The apex was shifted down and out and a third as well as fourth heart sounds were also heard14. This 25 year-old man presented with gradual onset of exertional dyspnoea. Other symptoms included angina pectoris, fatigue, and occasional syncopal attacks. There was also a history of sudden cardiac death of his father. Clinical examination showed triple apical precordial impulse, a rapidly rising carotid arterial pulse, and a an S415. This 45 year–old lady presented with exercise intolerance & dyspnea. She also had dependent edema, ascites, and an enlarged, tender, and often pulsatile liver. The jugular venous pressure is elevated and did not fall normally, but rose with inspiration (Kussmaul's sign). The heart sounds were distant, and S3 and an S4 were also heard.16. This 35 year-old patient presented with low grade fever and finger tip gangrene. He also complained of weight loss, cachexia, malaise, arthralgia, rash, clubbing and pallor. On auscultation of the mitral area, a characteristic low-pitched sound that was audible during early or mid-diastole similar to a plopping sound, but no murmur.17. The patient was examined during a routine medical checkup and was found to have an abnormal position of the apex on the fifth right inter-costal space in the mid-clavicular line. Apart from this the patient was totally asymptomatic. Abdominal examination also showed the liver on the left side and spleen dullness on right side<br />
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