4. HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic performing her daily
activities 6 months ago when she started noticing breathlessness
when climbing 3 flight of stairs which she was previously able to
climb which was insidious in onset ,increased on exertion and
reduced on taking rest and sleep
The symptoms was gradually progressive such that since 2 months
the patient had frequent episodes of feeling breathlessness during
sleep which began about 2 hours after sleep and relieved on
sitting and deep breaths. For the above complaints patient was
taken to a local hospital 2 months ago and was told to have a heart
disease may require surgery & was given oral medications
following which patient felt symptomatically better and was able
to perform her daily routine activities with improvement in her
sleep.
5. The breathlessness further progressed to the current state
such that patient feels breathless even on sitting in the bed,
and worsens immediately after lying supine with no relief with
oral medications.
6. 2.Palpitations since 3 months, insidious in onset, progressive
in nature, such that patient experienced palpitations initially
on exertion lasting about 5-7 minutes, which was regular in
nature , relieved on taking rest ,oral medication and currently
feels regular palpitations even during rest which is felt
sometimes during sleep since the past 3 weeks.
3.Patient also developed painless swelling of bilateral lower
limb since 1 week such that patient noticed swelling uptil mid
calf which reduced partially on limb elevation.
7. No h/o chest pain/post palpitation diuresis/ syncope
No h/o fever
No h/o abdominal pain, yellowish discoloration of eyes
No h/o squatting episodes in childhood, bluish discoloration of
the body
No h/o cough ,hemoptysis
No h/o facial edema/reduced urine output/abdominal
distension
8. PAST HISTORY
No h/o fever, migratory joint pain, involuntary movements in
childhood.
No h/o Type 2DM, HTN ,Asthma,Tuberculosis
No h/o previous hospitalization or surgeries
9. FAMILY HISTORY
• Born of non consanguineous marriage
• No family history of sudden cardiac death
• No history of heart diseases in the family
10. PERSONAL HISTORY
• Consumed a vegetarian diet
• Appetite reduced since 1 months
• Sleep disturbed
• Bowel bladder habits regular
• Denies any high risk behavior or addictive habits
12. SUMMARY
My patient a middle aged lady with background history of
known heart disease presented with progressive
breathlessness since 6 months without wheeze initially NYHA
IIIV currently , exertional regular palpitations and pedal
edema
I would like consider the following possibilities
1.Ischemic Heart disease in congestive cardiac failure
2.Valvular Heart disease – Left sided ( regurgitation >stenosis)
Mitral valve >Aortic valve.
3.Adult Congenital heart disease(Left to right shunt)
13. GENERAL EXAMINATION
Middle aged female well built and nourished well oriented to time
place person
B/L pitting pedal edema
No pallor icterus cyanosis clubbing lymphadenopathy
BP :RUL – 130/70mmHg LUL – 138/70mmHg
RLL – 158/74mmHg LLL- 158/74 mmHg
[Impression : Hill sign positive]
PR: 87/min regular high volume,non collapsing, no thickened
vessel wall,All peripheral pulses well felt.No radio-radial/femoral
delay present.
Character : Pulsus bisferiens
JVP : not elevated above sternal angle.Normal waveforms
14. CARDIAC EXAMINATION
Central CVS
1) Inspection
No Thoracic wall abnormalities
No Precordial bulge
Trachea central
Apex beat visualised in the left 6th ICS 2cm lateral to
Midclavicular line
No scars/sinuses/venous engorgements
15. 2) Palpation
No tenderness
Apical impulse location: Left 6th ICS 2cm to mid clavicular line
character: Hyperdynamic
Grade I Parasternal heave
Diastolic thrill felt in left 3rd ICS
No suprasternal/epigastric/interscapular impulses
3) Percussion
Upper border of liver dullness at the Right 5th intercostal Space
Left heart border corresponds to Apex
Right heart border substernal
16. 4) Auscultation
Apex : S1normal, S2 heard, S3+
No murmurs
Left lower sternal border :S1 normal S2 heard.
No added sounds/murmurs
Left 3rd ICS :Grade 4 EDM best heard with bell of stethoscope patient
leaning forward with breath held in expiration
Right upper sternal area: S1 heard S2 soft
Crescendo –decrescendo mid systolic murmur grade III/VI with
diaphragm of stethoscope patient leaning forward with breath held in
expiration radiating to the carotid
Pulmonary area: S1 ,S2 heard.S2 single
No added sounds /murmurs
No peripheral signs of AR
17. DIAGNOSIS
VALVULAR HEART DISEASE In form of Severe Aortic
Regurgitation with mild Aortic stenosis in sinus rhythm in CCF
without evidence of Infective endocarditis or embolic
phenomenon currently in NYHA class III with medications
Etiology ?Biscuspid Aortic valve ?Rheumatic
