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Patient Case Study

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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Patient Case Study

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  1. Patient Case Study Mrs. J.A

  2. 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

  3. 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

  4. Cardiovascular Risk-factors • Unmodifiable • Age • Gender • Family Hx • Modifiable • Sedentary lifestyle • Smoking • Diabetes mellitus • Diet • Hypercholesterolemia • Hypertension

  5. 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??

  6. 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)

  7. 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

  8. 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

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