Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for mitral stenosis (MS)
(Specify) Symptoms may be absent in early stages.
With worsening MS: fatigue, shortness of breath (particularly with exertion), night sweats, paroxysmal nocturnal dyspnea (waking up short of breath at night), hemoptysis (coughing up blood – less common).
History of Present Illness:
Onset, duration, and severity of symptoms.
Functional limitations due to symptoms (e.g., exercise intolerance).
For established MS:
Progression of symptoms.
Response to previous treatment (medications, procedures).
Past Medical History:
Underlying conditions that may have caused MS:
Rheumatic fever (most common cause)
Congenital heart defects (mitral valve malformation)
Endocarditis (less common)
Risk factors for rheumatic fever (if applicable):
Untreated streptococcal throat infection (strep throat)
Medications:
List all current medications, including heart medications (diuretics, blood thinners).
Social History:
History of streptococcal infections (if applicable).
Family History:
Family history of rheumatic fever (may increase risk).
Physical Exam:
Vital signs: Assess for tachycardia (rapid heart rate), tachypnea (rapid breathing), and elevated jugular venous pressure (JVD) in severe cases.
Cardiovascular exam:
Listen for a characteristic murmur of mitral stenosis.
Assess for presystolic murmur (heard just before heartbeat) which is specific for MS.
Assess for pulmonary rales (crackles) in the lungs (fluid buildup with severe MS).
Assess for peripheral edema (fluid retention in legs) in severe cases.
Laboratory Tests:
Complete blood count (CBC) may be normal.
Basic metabolic panel (BMP) may reveal electrolyte abnormalities with severe heart failure.
Brain natriuretic peptide (BNP) levels may be elevated with heart failure.
Rheumatic fever serologic tests may be considered to support a diagnosis of rheumatic fever as the cause of MS (not always positive).
Imaging Studies:
Chest X-ray: May show cardiomegaly (enlarged heart) and pulmonary edema (fluid in lungs) in severe cases.
Electrocardiogram (ECG): May show atrial fibrillation (irregular heart rhythm) which can worsen MS.
Echocardiogram: The definitive test for diagnosing MS. It assesses the severity of stenosis (valve narrowing), valve anatomy, and left and right atrial size.
Assessment:
Mitral stenosis: Based on clinical presentation (symptoms, physical exam findings), echocardiogram results, and presence of underlying cause (usually rheumatic fever).
Severity of MS: Echocardiogram classifies MS severity (mild, moderate, severe) based on the degree of valve narrowing and pressure gradient across the valve.
Left atrial size: Echocardiogram measures left atrial size, which can indicate the degree of backflow through the narrowed mitral valve.
Presence of pulmonary hypertension: Echocardiogram can assess for signs of elevated pulmonary artery pressure due to chronic backflow through the mitral valve.
Plan:
Treatment depends on the severity of MS and symptoms:
Asymptomatic or mild MS: Regular monitoring with echocardiograms. May consider prophylactic antibiotics to prevent recurrent rheumatic fever if applicable.
Moderate MS with symptoms: Medications (diuretics, blood thinners) to manage symptoms and improve heart function. Consider balloon valvuloplasty (minimally invasive procedure to open the valve) if symptoms worsen.
Severe MS with significant symptoms or worsening heart function: Mitral valve surgery (repair or replacement) is often necessary to prevent heart failure.
Lifestyle modifications: Recommend a healthy lifestyle to improve heart health, including:
Diet modifications (low-salt, low-fat diet)
Weight management
Regular exercise (as tolerated)
Smoking cessation (if applicable)
Follow-up: Schedule regular follow-up visits with repeat echocardiograms to monitor disease progression and treatment response.