63 year old female with c/o shortness of breath since 3 days,
History of present illness: patient was apparently alright 7 years back then she developed shortness of breath, chest pain - retrosternal then incidentally she was diagnosed with sinus venosus ASD, managed conservatively , since then she developed shortness of breath initially grade 2 to grade 3 associated with chest pain/midscapular pain radiating to axilla, orthopnea +, paroxysmal nocturnal dyspnea+ since 2 days
K/c/o sinus venosus ASD diagnosed 7 years back
N/k/c/o HTN, DM, Asthma, Epilepsy
Loss of appetite since 3days
Constipation since 3 days
Teetotaler alcohol consumer
O/E:
Patient is conscious, coherent, cooperative
Pallor, clubbing present
No icterus, cyanosis, lymphadenopath, edema
Temperature- afebrile
Pulse rate- 85 bomb
Bp- 120/80 mm Hg
Respiratory rate- 20 cpm
Personal history:
CVS:
S1 S2 heard
Murmurs present
RESPIRATORY SYSTEM:
Dyspnea+
Centrally positioned trachea
Vesicular breath sounds
Crepts heard
ABDOMEN:
Soft, non tender
Bowel sounds heard
CNS:
PROVISIONAL DIAGNOSIS:
SINUS VENOSUS ASD WITH MODERATE PAH
2D ECHO:
X-RAY T SPINE:
serum creatinine:
serum urea:
History of present illness: patient was apparently alright 7 years back then she developed shortness of breath, chest pain - retrosternal then incidentally she was diagnosed with sinus venosus ASD, managed conservatively , since then she developed shortness of breath initially grade 2 to grade 3 associated with chest pain/midscapular pain radiating to axilla, orthopnea +, paroxysmal nocturnal dyspnea+ since 2 days
K/c/o sinus venosus ASD diagnosed 7 years back
N/k/c/o HTN, DM, Asthma, Epilepsy
Loss of appetite since 3days
Constipation since 3 days
Teetotaler alcohol consumer
O/E:
Patient is conscious, coherent, cooperative
Pallor, clubbing present
No icterus, cyanosis, lymphadenopath, edema
Temperature- afebrile
Pulse rate- 85 bomb
Bp- 120/80 mm Hg
Respiratory rate- 20 cpm
Personal history:
CVS:
S1 S2 heard
Murmurs present
RESPIRATORY SYSTEM:
Dyspnea+
Centrally positioned trachea
Vesicular breath sounds
Crepts heard
ABDOMEN:
Soft, non tender
Bowel sounds heard
CNS:
Higher Mental functions :Intact
No signs of meningeal irritation
(Kernigs sign_negative,Brudzinski Sign_negative)
Cranial nerves: intact
Motor system: intact
Sensory system:intact
REFLEXES RIGHT. LEFT
Biceps 2+. 2+
Triceps. 2+. 2+
Knee jerk. 2+. 2+
Ankle jerk. 2+. 2+
Plantar reflex. Flexor. Flexor
PROVISIONAL DIAGNOSIS:
SINUS VENOSUS ASD WITH MODERATE PAH
INVESTIGATIONS:
CBP:
Hemoglobin-12.6%
Total leucocyte count- 8200
Neutrophils-
Lymphocytes-
Monocytes-
Esinophils-
Normochromic normocytic thrombocytopenia
ECG:
2D ECHO:
X-RAY T SPINE:
serum creatinine:
serum urea:
43 gm/dl
ABG:
pH-
pCO2-
pO2-
HCO3-
