A 21-year-old known cardiac patient presented with worsening shortness of breath, orthopnea, palpitations, and intermittent coughing up of blood over the past week. On physical examination, she was in cardiorespiratory distress, had an irregularly irregular pulse, raised JVP, tapping PMI, apical diastolic thrill, and a grade 4 rumbling mid-diastolic murmur. She has signs of congestive heart failure. Based on her history and presentation, she has NYHA class IV stage C congestive heart failure secondary to valvular heart disease, with arrhythmia as a precipitant, and a mid-systolic murmur. Echocardiogram

1. CASE
 A 21 years old known cardiac patient for the
past six years on Lasix, spironolactone,
enalapril, monthly benzathine penicillin and
follow up in GUH
 Currently presented with worsening
shortness of breath of one week duration. It
was initially while she was going to school but
now at rest. ass’ted with this she has
orthopnea of 2-3 pillow, PND ,palpitation but
no leg swelling

2. Cont’d
She has dry cough and intermittent coughed
up blood but no fast breathing, chest pain
She has no fever, recent migratory type of
joint pain
She has no hx of GI or gu manipulation or no
hx of sweating, malaise, reddish discoloration
of urine
She is adherent to her medications and
dietery advice

3. She has no neck swelling or hx of hot or cold
intolerance
She has no self or family hx of HTN
She is single and didn’t get pregnant
She has no BV, tinnitus or vertigo
p/e
G/A- in cardiorespiratory distress
v/s- Afebrile, BP=90/60

4. Cont’d…..
 Chest: basal criptation bilaterally
 Cvs:
Arterial pulse is low in volume and it is
irregularly irregular
Jvp is raised
AI Is not visible but PMI is at 5th ics,at MCL, and
it is tapping.
P2 is palpable
There is apical diastolic thrill
There is parasternal heave

5. Cont’d…..
 Auscultation reveals:
 Loud s1,p2
 Grade 4, rumbling, mid diastolic murmer, best
heard at the apex, and accentuated by expiration
 Abdomen :no hepatosplenomegally
 MSS: bilateral G1 leg edema
 IS: bilateral erethamathos skin over her check
Based on the above evidence answer the following
Q.?

6. Cont’d…
1. Write full ass’t of this pt?
2. Did she has a precipitant? If yes what is z
precipitant?
3. What is the murmur of this patient?
4. What important investigation do u want to send??
ANSWER
1 NHYA CLASS IV STAGE C CHF 20 TO VHD
2ARRYTHIMIA
3MS
4 ECHO C X RAY ECG

7.  thank u so much !!!!!