A 53yr old with SOB on exertion
Pedal edema since 3months
Epigastric pain since 15 years
Patient was apparently asymptomatic 15 years ago.then he had bloating and epigastric pain for which he consulted a local doctor and took medication. He developed shortness of breath 2 years ago nyha grade 3 for which he went to a hospital in west bengal and diagnosed to have severe AS,moderate AR for which he is taking medications
Past reports:
4th sept 2020
Coronary angiography was done:
Since 3 months his SOB has increases to nyha grade 4 , PND +
Past history
Not a known case of DM,HTN,ASTHMA,EPILEPSY,THYROID DISORDERS
PERSONAL HISTORY-
Diet-mixed
Appetite-normal
B &B movements- regular
Sleep-Inadequate (PND+)
Addictions- nil
GENERAL EXAMINATION-
Patient is conscious, coherent, cooperative
Moderately built and moderately nourished
Oriented to time ,place and person
No signs of pallor,icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
VITALS AT ADMISSION:
Afebrile
BP-110/60 mmhg
PR-68bpm
RR-18cpm
6MWT
Vitals before testing :
PR 64 bpm
RR 28 cpm
BP 110/60 mmHg
SPO2 99% @RA
Distance covered: 191.25 meters
Duration: 6mins
Vitals after testing:
PR 74 bpm
RR 34 cpm
BP 100/60 mmHg
SPO2 98%@RA
SYSTEMIC EXAMINATION:
RS:BAE+
CVS:s1s2+
P/A: soft,nontender
CNS :NAD
2d echo
PROVISIONAL DIAGNOSIS:
AORTIC STENOSIS WITH MITRAL REGURGITATION
20/5/22, day 1
53 yr old with SOB on exertion
SOAP NOTES
S-
NO FRESH COMPLAINTS
O-
Patient is conscious/coherent/ cooperative
No pallor /icterus/cyanosis/clubbing/lymphadenopathy
Vitals:
Temp: 98F
BP: 110/80 mmhg
PR: 92bpm
RR: 16 cpm
Systemic examination:
CVS - S1 S2 heard,
mid systolic murmer aortic area
RS- BAE + ,NVBS HEARD
P/A - SOFT ,NON TENDER
A- AORTIC STENOSIS with MITRAL REGURGITATION
P-
1.NORMAL DIET
2.T.PANTOP 40mg OD
3.T.STORVAS-CV 20mg PO /HS
4.T.LASILACTONE 50mg PO/1/2 tab BD
21/5/22, day 2
53 yr old with SOB on exertion
SOAP NOTES
S-
NO FRESH COMPLAINTS
O-
Patient is conscious/coherent/ cooperative
No pallor /icterus/cyanosis/clubbing/lymphadenopathy
Vitals:
Temp: 98F
BP: 110/70 mmhg
PR: 84bpm
RR: 16 cpm
Systemic examination:
CVS - S1 S2 heard,
mid systolic murmer aortic area
RS- BAE + ,NVBS HEARD
P/A - SOFT ,NON TENDER
A- AORTIC STENOSIS with MITRAL REGURGITATION
P-
1.NORMAL DIET
2.T.PANTOP 40mg OD
3.T.STORVAS-CV 20mg PO /HS
4.T.LASILACTONE 50mg PO/1/2 tab BD
22/5/22, day 3
53 yr old with SOB on exertion
SOAP NOTES
S-
NO FRESH COMPLAINTS
O-
Patient is conscious/coherent/ cooperative
No pallor /icterus/cyanosis/clubbing/lymphadenopathy
Vitals:
Temp: 98F
BP: 120/80 mmhg
PR: 86bpm
RR: 16 cpm
Systemic examination:
CVS - S1 S2 heard,
mid systolic murmer aortic area
RS- BAE + ,NVBS HEARD
P/A - SOFT ,NON TENDER
A- AORTIC STENOSIS with MITRAL REGURGITATION
P-
1.NORMAL DIET
2.T.PANTOP 40mg OD
3.T.STORVAS-CV 20mg PO /HS
4.T.LASILACTONE 50mg PO/1/2 tab BD
