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Patient Case Study. Mrs. J.A. History of Presenting Complaint. 59 yo female Biprosthetic AV replacement CABG x2 (Last thurs – 5 days post-surgery) Release from ICU on Monday, recovering well Stage IV dyspnoea : SOB at rest

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Presentation Transcript
history of presenting complaint
History of Presenting Complaint
  • 59 yo female
  • BiprostheticAV replacement
  • CABG x2 (Last thurs – 5 days post-surgery)
  • Release from ICU on Monday, recovering well
  • Stage IV dyspnoea: SOB at rest
  • First presentation of problem difficult to determine the patient has a mild intellectual disability
past history
Past History
  • IHD, HTN, Hypercholesterolaemia, AS, intellectual impairement, OA
  • No previous hospital admissions (apart from wisdom teeth)
  • Social H(x): Retired, lives in supportive care, nil smoking/ alcohol history, no drugs
cardiovascular risk factors
Cardiovascular Risk-factors
  • Unmodifiable
    • Age
    • Gender
    • Family Hx
  • Modifiable
    • Sedentary lifestyle
    • Smoking
    • Diabetes mellitus
    • Diet
    • Hypercholesterolemia
    • Hypertension
systems review on presentation
Systems Review (on presentation)
  • Syncope
  • Angina
  • Fatigue
  • Edema- Denied ankle swelling (present on examination)
  • Dyspnoea- Excertionaldyspnoea (No orthopnea or PND)
  • Palpitations – frequency 3-4 hours
  • “Cramps’ in the legs – intermittent claudication??
medications
Medications
  • Paracetamol
  • Pantoprazole (PPI) (proton pump inhibitor)
  • Cephazolin (1st generation cephalosporin)
  • Aspirin
  • Heparin
  • Ezetimibe(cholesterol GI absorption inhibitor)
  • Felodipine (Ca channel blocker)
  • Lipitor (Atorvastatin calcium, HMG-CoAreductase inhibitor)
  • Meloxicam (selective COX-2 inhibitor)
  • Monoplus (Fosinopril sodium + hydrochlorothiazide) (ACE + Diuretic)
examination
Examination

General Inspection

  • Normal diet, nil walking aids, well, no monitors, IV in left hand, multiple IV puncture sites, site of removal of central line
  • Patient appears generally well, overweight women, mildly impaired mental state
  • Surgical scar central thoracic healing well, nil pain
  • Drains & temp pacemaker removed this morning

Hands

  • Hands – clubbing, nil other
  • Pulse – 65bpm, BP 110/70, Temp 37.6 (afebrile)
  • No RR/RF delay

Face

  • Nil – face
  • Nil carotids
  • JVP normal

Chest

  • Soft ejection systolic murmur aortic region radiating to back
  • Lung field clear
  • Nil other sounds, vocal resonance etc normal

Abdomen

  • No organomegaly

Legs

  • Pitting odema to ankle
investigations
Investigations
  • Bloods - all normal, except prolonged INR-2.6 (0.8–1.2) & decreased Hb-96 (anaemia of chronic disease)
  • Chest X-ray - see online URL 4090121
  • Angiograms - see online also
  • ECG - sinus rhythm, normal