Siheyuan: living in a prosperous era

Chapter 98 Live Teaching
"This comrade's heart sound sounds rumbling, which should be the mitral and tricuspid stenosis that the teacher mentioned."

"Well, I think so too."

After listening to Yang Shuning's formula for heart murmur, Zhu Cong felt that this patient had the mitral and tricuspid stenosis mentioned in the formula.

Because Ding Qiunan had studied with Yang Shuning for a long time, Yang Shuning had already guided him on many issues, and even had a preliminary treatment plan for this patient's condition.

"Comrade, your condition is very characteristic of clinical experience. If you allow me, I would like to teach my students based on your condition. Of course, you can also listen. Is that okay?"

Yang Shuning asked the patients for their opinions as usual before clinical teaching.

"Of course, I don't mind, and I can also listen to my condition."

The patient agreed, and Yang Shuning began to ask questions:
"Congcong, since you think it is mitral and tricuspid valve stenosis, does this comrade have mitral valve stenosis, tricuspid valve stenosis, or both mitral and tricuspid valve stenosis?"

"First think about the answer, and then tell me why you think so."

Yang Shuning further asked, if you want to improve the level of medicine, you must constantly develop problems, ask questions, and solve problems.

"I'm sorry, teacher, I don't know."

After all, Zhu Cong had not been with Yang Shuning for a long time, and he had not understood many issues.

"Let me talk about it first. Mitral and tricuspid stenosis in the heart refers to the incomplete opening of the valves in the passage between the atrium and the ventricle, preventing blood from flowing normally."

"Mitral and tricuspid valve stenosis can be caused by a variety of cardiovascular diseases. The first and most common one is rheumatic heart disease. When the valve is involved, valve stenosis or insufficiency will occur."

"The second is hypertensive heart disease. Due to the hypertrophy or enlargement of the myocardium, it will cause the relative expansion of the valve annulus or the damage of the valve leaflets, leading to mitral and tricuspid valve insufficiency."

"This comrade's blood pressure just now was 161/98mmhg. Hypertensive heart disease should be considered."

"It is also possible that it is ischemic cardiomyopathy, which can also lead to insufficiency or rupture of the chordae tendineae, causing mitral or tricuspid regurgitation."

"In addition, there may be myocarditis, infective endocarditis, various types of cardiomyopathy, etc., which may lead to insufficiency of the mitral and tricuspid valves."

"Older patients may also be caused by cardiac degeneration."

"In our clinical practice, once tricuspid valve stenosis occurs, it is often accompanied by obvious signs of right heart congestion. And systemic vein congestion can cause intractable edema, liver enlargement, ascites, and splenomegaly. , jaundice, severe malnutrition, generalized edema and other symptoms.”

"Mitral stenosis is a common heart valve disease. The main causes are repeated infections of rheumatic fever and degenerative diseases in the elderly."

Yang Shuning looked at Zhu Cong taking notes carefully and nodded in approval. A good memory is not as good as a bad pen. Key knowledge should be written down in notes.

However, Yang Shuning's speech still interrupted Zhu Cong's record:

"Congcong, look at this comrade. When you did the physical examination just now, you could feel his liver and spleen, which are palpable under his ribs, but it's not very obvious. It can be seen that his liver and spleen have been slightly enlarged."

"And you see, the patient's face is slightly yellow, and although his hands are not obvious, edema has appeared in both lower limbs, which is consistent with the characteristics of jaundice and limb edema."

"The points I just mentioned are also consistent with the signs of right heart congestion caused by tricuspid valve stenosis." "Now go and ask about this comrade's condition in more detail."

After Zhu Cong finished asking, Yang Shuning also told the patient about his arrangements:
"Comrade, please go and take a chest X-ray first, and then come back after you have finished taking the chest X-ray."

After the patient left, Yang Shuning continued to teach Zhu Cong,

"During the physical examination of tricuspid stenosis, you need to inspect the patient first. You will find that the patient has jugular venous distension, accompanied by obvious systolic fluctuations, which increase during inspiration."

"The right ventricular pulse can be felt as a high-dynamic impact during palpation. The liver can be enlarged and tender in the abdomen, and the hepatic jugular reflux sign is positive (pressing the liver with hands can cause the expansion of the jugular vein). In severe cases, there may be abdominal cavity Effusion.”

"During auscultation, if there is severe reflux, there will be a third heart sound at the lower left edge of the sternum, which will increase during inhalation; a high-pitched, blowing-like holosystolic murmur can be heard at the left edge of the sternum, and the loudest sound will be at the left lower edge of the sternum or the xiphoid process area. When the heart is enlarged and occupies the apical area, the apical area is most obvious; when the tricuspid valve prolapses, there is a systolic click sound."

"You must arrange an X-ray examination for the patient. You will find that patients with tricuspid stenosis will have: the right atrium is significantly enlarged, the right ventricle, superior vena cava, and azygos vein are enlarged; sometimes there is pleural effusion, and patients with ascites can see transverse The diaphragm is raised.”

"It's a pity that the factory hospital has not yet applied for an electrocardiogram machine. Otherwise, if you perform an electrocardiogram on the patient, you will find that the common patients have right atrial enlargement, right ventricular hypertrophy and strain, incomplete right bundle branch block, and atrial fibrillation."

Yang Shuning didn't mention B-ultrasound examination, because many big hospitals don't have B-ultrasound now, let alone the steel rolling mill hospital.Because all current B-ultrasound machines are imported, precious foreign exchange must be spent to buy them.

Because B-ultrasound machines are not popular now, Yang Shuning did not say anything.

By the time the patient came back with his chest, more than an hour had passed, and Yang Shuning had already seen many more patients.

Yang Shuning held the patient's chest and said to Zhu Cong:

"Congcong, please take a look at this comrade's chest X-ray. It matches the characteristics I just mentioned."

"Well, yes, teacher." At this time, Zhu Cong was like a chicken pecking at rice, bit by bit.

Since Yang Shuning had confirmed that the patient had hypertension and tricuspid stenosis, he said to Zhu Cong and Ding Qiunan:

"Since this comrade has tricuspid stenosis caused by hypertension, and currently still has mild regurgitation, we must control the hypertension to improve the regurgitation."

"The second is to limit the patient's sodium intake. We can use diuretics and vasodilators to control the ventricular rate of atrial fibrillation."

"With diuretics, we can increase the patient's urine output, thereby eliminating edema and reducing the load on the heart."

"Using venodilators can reduce venous return and improve pulmonary congestion."

After talking to Zhu Cong, Yang Shuning said to the patient:
"Comrade, from now on, you should eat more soft and easy-to-digest food. For example, porridge, paste, and the like."

"And you should pay attention to the intake of dietary fiber, that is, eat more vegetables to keep your stool smooth and avoid dry stool, which aggravates heart failure when straining to defecate."

As for reducing sodium intake and eating a low-salt and low-fat diet, Yang Shuning goes without saying.Now is not the future, any worker who is not low-salt and low-fat has no chance of getting high.

(End of this chapter)