Case presentation

1. CASE PRESENTATION ON
MITRAL valve STENOSIS
WITH
TRICUSPID REGURGITATION
BY
14421T0009
Pharm.D IV YEAR

2. • IP.NO: 0001790
• AGE: 85Y
• SEX: feamle
• DOA: 08-01-2018
• WARD: 02-GM
• UNIT: 07

3. • C/O Swelling of lower limbs since 10 days
• Similar complaints 3 months back, subsided.
• H/O shortness of breath
• H/O exertional dyspnoea, orthopnea
• H/O cough a/w sputum since 5 days
• H/O pain in lower limb since 8 days.
• No h/o facial puffiness, abdominal distension, decreased
urine output, burning micturition, palpitations, chest pain

4. • Not a k/c/o DM/HTN
• No h/o TB, Epilepsy, asthma, CVA, CAD
• Takes mixed diet.
• Bowel and bladder normal.
• Decreased appetite since 15 days.

5. PARAMETER OBSERVED VALUE NORAML VALUE
HGB 4.6g/dl 12-17g/dl
RBC 1.88mill/cc 3.8-4.8mill/cc
WBC 5500/ cumm 4000-11000/ cumm
PLATELET 1.41lakhs/cumm 1.5-4lakhs/ cumm
BLOOD UREA 47mg/dl 7-20mg/dl
Sr.CREATININE 1.8mg/dl 0.6-1.3mg/dl
Sr.ELECTR
OLYTES
136mmol/l 134-144mmol/l
3.4mmol/l 3.5-5mmol/l
96mmol/l 96-108mmol/l

7. WITH
MITRAL STENOSIS:
Mitral stenosis is the narrowing of the mitral valve
opening that blocks the blood from the left atrium to the left
ventricle.
TRICUSPID REGURGITATION:
Tricuspid regurgitation is a disorder in which this
valve does not close tight enough. This problem causes
blood to flow backward into the right upper heart chamber
(atrium) when the right lower heart chamber (ventricle)
contracts

8.  2/3rd of all the patients with mitral stenosis are females.
 Juvenile mitral stenosis is common in India.
 ½ of the patients with MS will give a history of rheumatic
fever.
SEVERITY/STAGE MITRAL VALVE ORIFICE
Minimal >2.5 cmsq.
Mild 1.4-2.5 cmsq.
Moderate 1.0-1.4 cmsq.
severe <1.0 cmsq.

9. MITRAL STENOSIS
• Rheumatic fever
• Congenital mitral stenosis
• Coxsackie B virus
• Mitral annular
calcification
• Infective endocarditis
• Rheumatoid arthritis
TRICUSPID REGURGITATION
• Ebstein's anomaly
• Infective endocarditis
• Carcinoid syndrome
• Implantable device wires
(leads)
• Endomyocardial biopsy
• Blunt chest trauma
• Rheumatic fever
• Congenital heart defects
• Marfan syndrome
• Radiation

10. Mitral valve stenosis
Increase in left atrial pressure left atrial dilation
Pulmonary venous hypertension atrial fibrillation stasis of blood
Pulmonary arterial hypertension thrombus formation
Right ventricular hypertrophy systemic embolism
Right ventricular dilation Right ventricular failure
Tricuspid valve dilation
Functional tricuspid regurgitation

11. • Dyspnea
• Breathlessness
• Orthopnea
• Increased pulmonary
capillary pressure
• Pulmonary edema
• Pedal edema
• Hemoptysis
• Bronchitis
• Palpitations
• Fatigue
• Loss of appetite
• Chest pain
• Electrocardiogram
• Echocardiogram
• Cardiac marker tests
• Complete blood count
• Chest X-ray
• Cardiac catheterization

12. DAY-1 DAY-2
O/E, Pt is C/C
P+, I-, Cy-, Cl-, PE+
PR: 98/min
BP: 130/60mmHg
CVS: S1S2+
RS: B/L crepts+
P/A: soft, no organomegaly
CNS: No FND
Rx
1.inj. AUGMENTIN 1.2g IV BD
2.Inj. METROGYL 100ml IV TID
3.Inj. LASIX 40mg BD
4.Inj. OPTINEURON 1amp IM OD
5.Inj. ENOXAPARIN 40mg SC OD
6. T. ACITROM 1mg OD
7. Syp. AMBROXOL 5ml TID
8. Plan for packed cell transfusion
O/E, Pt is C/C
P+, I-, Cy-, Cl-, PE+
PR: 104/min
BP: 130/70mmHg
CVS: S1S2+
RS: B/L crepts+
P/A: soft, hepatomegaly+
CNS: No FND
Rx
1.inj. AUGMENTIN 1.2g IV BD
2.Inj. METROGYL 100ml IV TID
3.Inj. LASIX 40mg BD
4.Inj. OPTINEURON 1amp IM OD
5.Inj. ENOXAPARIN 40mg SC OD
6.T. WARF 5mg OD
7.T. ECOSPRIN 75mg OD
8.T. DIGOXIN 0.25mg 5/7 0-1/2-0
9.T. ALDACTONE 25mg OD
10.T. ENAM 2.5mg OD

13. DAY-3 DAY-4
O/E, Pt is C/C
C/O pain in right lower limb
P+, I-, Cy-, Cl-, PE+
PR: 98/min
BP: 130/70mmHg
CVS: S1S2+
RS: B/L wheez+
P/A: soft, hepatomegaly+
CNS: No FND
Rx
1.inj. AUGMENTIN 1.2g IV BD
2.Inj. METROGYL 100ml IV TID
3.T. DIGOXIN 0.25mg 5/7 0-1/2-0
4.T. ALDACTONE 25mg OD
5.T. ENAM 2.5mg OD
6.Inj. OPTINEURON 1amp IM OD
7.T. ASPIRIN 75mg OD
8.T. SERRATIOPEPTIDASE TID
9.Inj. TRAMADOL IM BD
O/E, Pt is C/C
Pain and swelling decreased
P+, I-, Cy-, Cl-, PE+
PR: 96/min
BP: 130/70mmHg
CVS: S1S2+
RS: B/L crepts+
P/A: soft, hepatomegaly+
CNS: No FND
Rx
1.inj. AUGMENTIN 1.2g IV BD
2.Inj. METROGYL 100ml IV TID
3.T. DIGOXIN 0.25mg 5/7 0-1/2-0
4.T. ALDACTONE 25mg OD
5.T. ENAM 2.5mg OD
6.Inj. OPTINEURON 1amp IM OD
7.T. ASPIRIN 75mg OD
8.T. SERRATIOPEPTIDASE TID
9.Inj. TRAMADOL IM BD

14. DRUG DOSE ROA FREQUEN
CY
DURATION
D1 D2 D3 D4
Inj. AUGMENTIN 1.2g IV BD + + + +
Inj. METROGYL 400mg IV TID + + + +
Inj. LASIX 40mg IV BD + + - -
Inj. OPTINEURON 1amp IM OD + + + +
Inj. ENOXAPARIN 40mg SC BD + + - -
T. ACITROM 1mg PO OD + - - -
Syp.AMBROXOL 5ml PO TID + - - -
T. WARF 5mg PO OD - + - -
T. ECOSPRIN 75mg PO OD - + - -
T. DIGOXIN 0.25mg PO 5/7 OD - + + +
T. ALDACTONE 25mg PO OD - + + +
T. ENAM 2.5mg PO OD - - + +
T. ASPIRIN 75mg PO OD - - + +
T. SERRATIOPEPTIDASE --- PO TID - - + +
Inj. TRAMADOL --- IM BD - - + +

15. CLINICAL CONDITION : MS With TR
DRUG OF CHOICE :DIGOXIN
CONTRAINDICATIONS : nil
DRUGS : appropriate
DOSES : doses for tramadol &
serratiopeptidase were not mentioned
DOSAGE FORMS : appropriate
FRQUENCY : appropriate
DURATION : appropriate
GUIDELINES : American Heart Association

16. DRUGS SEVERIT
Y
EFFECT MANAGEMENT
Aspirin X
Enoxaparin
Major long-term or permanent
paralysis
Close clinical and
laboratory observation for
bleeding complications is
recommended
Warfarin X
Enoxaparin
Major long-term or permanent
paralysis
Close clinical and
laboratory observation for
bleeding complications is
recommended
Warfarin
X
Metronidazole
Major increase the plasma
concentrations and
hypoprothrombinemic effect
of warfarin
The INR should be checked
frequently
Warfarin X
Aspirin
Major increase the risk of bleeding
in patients
monitoring for excessive
anticoagulation and overt and
occult bleeding is recommended.
Enalapril X
Spironolactone
Major increase the risk of
hyperkalemia.
Serum potassium and renal
function should be checked
regularly

17. Enalapril X
Furosemide
Moderate Coadministration makes
hypotension and
hypovolemia
Monitoring of blood pressure,
diuresis, electrolytes, and renal
function is recommended during
coadministration
Enalapril X
Enoxaparin
Moderate increase the risk of
hyperkalemia
Serum potassium and renal
function should be checked
regularly
Aspirin X
Digoxin
Moderate increase plasma digoxin
concentrations and half-life.
The digoxin dosage may require
adjustment.
Furosemide
X Digoxin
Moderate hypokalemia and
hypomagnesemia
Hypokalemia and
hypomagnesemia should be treated
appropriately
Enalapril X
Digoxin
Moderate decrease the renal clearance
of digoxin
digoxin levels should be monitored
Enalapril X
Aspirin
Moderate the vasodilator and
hypotensive effects of ACE
inhibitors.
regular blood pressure AND
clinical monitoring such as renal
function assessments.
Warfarin X
Amoxicillin
Moderate potentiate the risk of bleeding
in patients
Caution is recommended

18. REGARDING DISEASE:
Mitral valve stenosis is the blockade of blood flow from the left
atrium to the left ventricle . It may be caused by any of the etiology. It can be
managed with drugs. If not treated it may lead to death also.
REGARDIND DRUGS:
AUGMENTIN:
• Used to treat bacterial infections.
• Given by nurse at morning and night.
• It may cause itching, diarrhea, rash.
METROGYL:
• Used to treat infections.
• Should be given by nurse, 3 times daily.
• It may cause anorexia, nausea, vomiting.
LASIX:
• Used to increase urine output
• Given by nurse at morning and night.
• It may cause shock, hypokalemia, hyperglycemia.

19. AMBROXOL:
• Used to treat nasal congestion & BLN
• should be taken 3 times daily
• It may cause nausea, vomiting, diarrhea.
ENOXAPARIN:
• Used to prevent clot formation.
• Given by nurse at morning and night.
• It may cause bleeding, nausea, edema, gum hyperplasia
ACITROM:
• Used to prevent clot formation.
• Should be taken one time daily.
• It may cause bleeding, dizziness, black stools, hematuria.
WARAFRIN:
• Used as anticoagulant.
• Should be taken one time daily.
• It may cause bleeding, GI disturbances.
ECOSPIRIN:
• Used as anticoagulant.
• Should be taken one time daily.
• It may cause bleeding, bronchospasm, ulcers.

20. DIGOXIN:
• Used to increase force of contraction of heart
• Should be taken once daily, ½ tablet.
• It may cause nausea, headache, facial pain, photophobia.
ALDACTONE:
• Used to increase urine output
• Should be taken once daily
• It may cause drowsiness, ataxia, mental alteration.
ENALAPRIL:
• Used to decrease blood pressure.
• Should be taken once daily.
• It may cause hypotension, angioedema.
SERATIOPEPTIDASE:
• Used to treat pains
• Should be taken 3 times daily.
• It may cause ulcers, bleeding, nausea, vomiting.
TRAMADOL:
• Used to treat pains
• Given by nurse 2 times daily.
• It may cause nausea, vomiting, ulcers.

21.  Exercise and diet - Talk to your doctor about appropriate dietary changes and
levels of exercise. Exercise keeps the body strong and can help reduce high
cholesterol and blood pressure.
 Heart-Healthy Nutrition - including tips and recipes that will help you limit
salt in your diet and develop other eating habits that will reduce your risk of more
valve problems.
 Infection prevention - reduce your chances of contracting rheumatic fever
 Be active, but you might need to avoid strenuous exercise.
 Get a flu vaccine every year. Get a pneumococcal vaccine shot. If you have had
one before.
 Limit salt - Salt in food and drinks may increase pressure on your heart. Don't
add salt to food, and avoid high-sodium foods.
 Cut back on caffeine - Caffeine can worsen irregular heartbeats (arrhythmias).
Ask your doctor about drinking beverages with caffeine, such as coffee or soft
drinks.