Asd long case

Asd long case

1. Department of Cardiology DMCH Case Presentation

2. Name - Mrs. Nazma Begum Age -55years Sex -Female Occupation - Housewife Marital status - Married Religion - Islam Address – kapasia , Gazipur Date of admission - 22/7/2017 through OPD Date of Examination - 27/07/2017 Particulars of the patient Cardiology DMCH

3. Breathlessness for 15 days Cough with mucoid expectoration for 20 days Palpitation for 5 months Weakness and easy fatiguability for 5 months Chief Complaints with duration Cardiology DMCH

4. According to the statement of the patient , she was reasonably well 5months back. Then she mentioned about few episodes of intermittent palpitation which are short lived, more on moderate to severe exertion, relieved by taking rest, not associated with chest pain, light-headedness, any episode of unconsciousness or polyuria, but associated with weakness and fatiguability H/O present illness Cardiology DMCH

5. Patient also complains about progressively increasing difficulty in breathing on moderate to severe exertion for last 20 days which is associated with nocturnal breathlessness at late hours of night for she has to get up from sleep, but gives no h/o breathlessness on lying flat, bluish discoloration of skin ( exertional ) and sweating. H/O present illness (continued) Cardiology, DMCH

6. She complains of cough with expectoration of mucoid sputum, but no hemoptysis or wheeze, not aggravated by exposure to cold, dust, fume and no seasonal variation. There is no history of chest pain, joint pain, abdominal swelling, loss of consciousness, jaundice. Her bowel and bladder habbit is normal. H/O present illness ( continued) Cardiology DMCH

7. Not significant Pt is non diabetic and normotensive Cardiology DMCH H/O past illness

8. She has two sons and one daughter. All are enjoying good health. Parents are not alive. Her brothers and sisters are also free from any significant/relevant illness. No such illness runs in her family Cardiology DMCH Family History

9. She belongs to a low socio-economic family. She lives in pucca house, drinks arsenic-free tubewell water and uses sanitary latrine. Socio-economic history Cardiology DMCH

10. She is in post- menopausal age Immunization History She was not immunized as per EPI schedule Cardiology DMCH Menstrual history

11. Appearance: ill looking Body built: average Co-operation: cooperative Decubitus: on choice Anaemia : absent Jaundice: absent Cyanosis: absent Koilonychia , leukonychia , clubbing, lymphadenopathy absent Thyroid gland not palpable Oedema :- bilateral pitting oedema (lower limbs) General Examination Cardiology DMCH

12. Pulse: 105beats/min , regular in rythm , no radio radial and radio femoral delay BP: 100/70 mm of Hg on both upper limbs Respiratory rate: 29 breaths/min Temp : 99 degree farenheit JVP: raised Contd … Cardiology DMCH

13. Pulse: 105beats/min (HR-107/min ), normal volume, regular in rythm No radio radial and radio femoral delay Condition of vessel wall normal All the peripheral pulses are normal Precordium : Inspection : No visible apical impulse No epigastric pulsation. No scar mark or bony deformity. Cardiovascular system Cardiology DMCH

14. Palpation:- Apex beat is left 5 th intercostal space, 9 cm from midsternal line, just medial to midclavicular line, thursting in nature Thrill:- Absent Palpable P2 in pulmonary area Left parasternal heave present No epigastric pulsation Cardiology DMCH Continued……

15. 1 st heard sound is normal in all areas Wide, fixed splitting of 2 nd heart sound with loud P2 There is an ejection systolic murmur in the left 2 nd and 3rd intercostal space with no radiation and grading of the murmur was 2/6. There is also high pitched mid diastolic murmur in tricuspid area. Bilateral basal crepitations present . Auscultation: - Cardiology DMCH

16. Reveals no abnormality. Other systemic examination Cardiology DMCH

17. Atrial septal defect with congestive cardiac failure Provisional DX Cardiology DMCH

18. Pulmonary stenosis Partial anomalous pulmonary venous connection Ventricular septal defect Differential Diagnosis Cardiology DMCH

19. In pulmonary stenosis- silent precordium, apperant no pulsation Thrill may be present in pulmonary area Soft or absent P2 wide splitting 2 nd heart sound present but not fixed ESM present, intensity increase with inspiration, may radiate to neck Cardiology DMCH Clinical differentiation……

20. PAPVC- Second heart sound widely split, but not fixed ESM both sides of sternal border VSD- Systolic thrill over left lower parasternal area Pansystolic murmur in left lower parasternal area Cardiology DMCH Continued…….

21. CBC : Hb : 14.1 gm/dl TWBC : 8200/mm3 Neu : 78 % Lym : 16% ESR : 10 mm in 1 st hour HCT : 44.60% Platelet : 206k/ uL Investigations Cardiology DMCH

22. S.Creatinine : 0.87 mg/dl RBS : 5.6 mmol /I S.Electrolytes : Na : 139mmol/l K: 4.00 mmol /l Cl : 100mmol/l HCO3: 27 mmol /l SGPT :- 25U/L Cardiology DMCH Continued…..

23. Lipid profile :- S. cholesterol :- 185mg/dl S. triglyceride :- 109mg/dl HDL :- 36mg/dl LDL :- 135mg/dl Cardiology DMCH Continued……..

24. Cardiology DMCH ECG

25. Cardiology DMCH Chest x ray P/A view

26. Cardiology DMCH

27. Cardiology DMCH

28. Atrial septal defect (septum secundum variety) with congestive cardiac failure with moderate pulmonary hypertension Final Diagnosis Cardiology DMCH

29. M edical management Interventional management Surgical management Treatment options Cardiology DMCH

30. Bed rest Propped up position High flow oxygen inhalation D iuretic- frusemide I/V S pironolactone ACE inhibitor Digoxin Cardiology DMCH Medical management

31. Cardiac catheterization Large ASD – surgical or device closure should be done ( if pulmonary flow to systemic flow 2:1 or more) If complication develop- ( e.g Eisenmenger’s syndrome) ,surgery is contraindicated. Cardiology DMCH further plan…..