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• First presentation of problem difficult to

determine the patient has a mild intellectual disability

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

• Unmodifiable– Age– Gender– Family Hx

• Modifiable– Sedentary lifestyle– Smoking– Diabetes mellitus– Diet– Hypercholesterolemia– Hypertension

Systems Review (on presentation)

• Syncope• Angina• Fatigue• Edema- Denied ankle swelling (present on

examination)• Dyspnoea- Excertional dyspnoea (No orthopnea or

PND)• Palpitations – frequency 3-4 hours• “Cramps’ in the legs – intermittent claudication??

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-CoA reductase inhibitor)• Meloxicam (selective COX-2 inhibitor)• Monoplus (Fosinopril sodium + hydrochlorothiazide) (ACE +

Diuretic)

ExaminationGeneral 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

• 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