CASE PRSENTATION

DR. SANDEEP KUMAR

RESIDENT FCPS CARDIOLOGY
 HISTORY
• BIODATA
• 65 YEARS OLD FEMLAE , MARRIED, HOUSEWIFE , RESIDENT OF
BALOCHISTAN , K/C DM-II ( SINCE 6 YEARS- ON OHG DRUGS ) , K/C
HTN , HX OF BASELINE DYSPNEA SINCE 6 YEARS , ADMITTED VIA OPD
( ON 5/12/2023) WITH C/O
• SOB (NYHA III-IV) ----------- 1 MONTH
• CHEST PAIN (FC III-IV) --------- 1 MONTH
• HOPC
• ACCORDING TO THE STATEMENT OF MY PATIENT’S ATTENDENTS , SHE HAS Hx
OF BASELINE DYSPNEA SINCE LAST 6 YEARS , WHICH NOW WORSENS SINCE
LAST ONE MONTH , OCCURS ON MILD EXERTION AS WELL AS IN REST ,
ASSOCIATED WITH ORTHOPNEA, COUGH DRY IN NATURE , AGGRAVATED IN
WINTER SEASON , RELIEVED BY TAKING INHALER AND NEBULIZATION .
• PATIENT HAS ALSO Hx OF CHEST PAIN , MODERATE TO SEVERE IN INTENSITY ,
LOCALIZED ,DULL IN CHARACTER , NON RADIATING , NON SHIFTING ,
OCCURS FOR 3- 5 MINUTES , NO SPECIAL TIME OF OCCURANCE , NO ANY
AGGRAVATING OR RELIEVING FACTOR , NO ANY ASSOCAITION
• SYSTEMIC HISTORY IS UNREMARKABLE , EXCEPT HAVING EPIGASTRIC
BURNING
• PAST MEDICAL Hx :--
• PATIENT HAS Hx OF MULTIPLE TIMES OF ADMISSION & OPD VISIT , DUE TO
SAME COMPLAIN SINCE LAST 3 YEARS
• HAD Hx OF TREATED PULMONARY TUBERCULOSIS , 20 YEARS BACK , TOOK
TREATMENT FOR 6 MONTHS
• HAS Hx OF ASTHMA , SINCE 2018
• HAD Hx OF IHD – NSTEMI ( EI PCI TO LAD ) IN 2021 @ QUETTA, BALOCHISTAN
• HAS Hx OF BILATERAL SEVERE STENOSIS OF RIGHT PULMONARY ARTERY &
LEFT PULMONARY STENOSIS , AND SEVERE STENOSIS OF LEFT UPPER VEIN
SINCE MARCH -2023
• PAST SURGICAL Hx :- NON- SIGNIFICANT
• PERSONAL Hx :- MARRIED , HUSEWIFE ,, NASWAR ADDICTED , DISTRUBED
SLEEP , DECREASED APPETITE , DECREASED INTAKE.
• FAMILY Hx :- HAVING 10 CHILD ( 2 DIED IN ROAD ACCIDENT , ALL OTHER ALL
STABLE ) , NO Hx OF ANY CHRONIC ILLNESS.
• DRUGS Hx:- PATIENT IS TAKING ANTI ISCHEMIC MEDICATION ( ASPIRIN ,
ROSUVASTATIN, ENALAPRIL , BISOPROLOL(ON/OFF) ,) ANTI- ASTHAMTIC
MEDICATION USING DRY POWDER INHALER ( DPI) , TOOK CARTICOSTEROIDS
ON/OFF. & ANTIBIOTICS AS PER NEED .
• SOCIOECOMIC Hx :- BELONGS TO POOR CLASS FAMILY , USE TAP WATER .
CASE SUMMARY :-
• 65 YEARS OLD FEMALE , HOUSE-WIFE ,RESIDENT OF BALOCHISTAN, NASWAR
ADDICTED , K/C DM-II (SINCE 6 YEARS ON OHG DRUGS ) , HTN , Hx OF
TREATED PULMONARY T.B ( 20 YEARS BACK ) , ASTHMA ( SINCE 2018 , ON DPI),
IHD (NSTEMI – S/P PCI O LAD ) 2021, K/C , B/L SEVERE STENOSIS OF RPA & LPA ,
SEVERE STENOIS OF LUPV (MARCH -2023 ) , Hx OF BASELINE DYSPNEA SINCE 6
YEARS, ADMITTED VIA OPD ON 5/12/2023, WITH C/O :-
• SOB ( NYHA III-IV ) ----------- 1 MONTH
• CHEST PAIN ( FC – III-IV ) ----------- 1 MONTH
•
•
EXAMINATION :-
• AN OLD AGE FEMALE WITH THIN BUILT & AVERAGE HEIGHT , ILL LOOK ,
WELL ORIENTED WITH TIME PLACE & PERSON , TACHYPNEIC , LYING IN LEFT
LATERAL POSITION ,WITH HAVING VITALS :-
• B.P:-
• PULSE :-
• TEMP :-
• R/R :-
• pSO2:-
• GENERAL PHYSICAL EXAMINATION :-
• ANEMIA ( -VE ) , JAUNDICE ( -VE) , CYANOSIS ( -VE ) , CLUBBING (-VE ) ,
• LYMPH NODE ( NON- PALPABLE ) , EDEMA ( -VE ) , JVP (-VE ) .
• PRE-CORDIUM EXAMINATION :-
• INSPECTION :- NO ANY CHEST DEFORMITY , NO VISIBLE PULSATION ,
BULDGING OR HAVE ANY SCAR MARK .
• PALPATION :- APEX BEAT IS PALPABLE IN 5th INTERCOSTAL SPACE IN
MIDCALVICULAR LINE , OF NORMAL CHARACTER , NO OTHER SOUND
PALPABE .
• AUSCULATION :- S1 & S2 ,BOTH ARE AUDIBLE , OF NORMAL INTENSITY , NO
ANY ADDED SOUND OR MURMUR IS APPRECIATED .
• RESPIRATORY EXAMINATION :- R/R IS 28 /Min, RESPIRATION IS
THORACO-ABDOMEN , TRACHEA IS CENTRALLY PLACED , NORMAL
VESICULAR BREATH WITH B/L WHEEZES OVER ALL THE CHEST .
• ABDOMINAL EXAMINATION :- SOFT, NON-TENDER , NO ANY
VISCEROMEGALY IS APPRECIATED .
• CNS EXAMINATION :- GCS 15/15 , SOMI ( -VE ) , PUPIL :- BERL , NORMAL
MOTOR EXAMINATION .
DIFFERENTIAL DIAGNOSIS

• ???
DIFFERENTIAL DIAGNOSIS

• DECOMPENSTED HEART FAILURE

• ACUTE EXACERABTION OF ASTHMA
• POST- T.B FIBROSIS
• B/L STENOS OF PULMONARY ARTERIES
ARRIVAL ECG SHOWS :- HR OF APPROX. 90 b/m , WITH REGULAR RHYTM , NORMAL AXIS DEVIATION , WITH T WAVE INVERSION IN ANT
LEADS ( V1-V4 ) .
CBC 5/12/23
Hb :- 11.5
TLC :- 20.5 K
PLT :- 290 K
ESR :- 60
CBC 5/12/23
CBC :- 12.1
TLC :- 21.6 K
PLT :- 269 K
ESR:- 85
CBC:-
HB :- 10.4
TLC :- 7.02K
PLT :- 346 K
UCE
CREATININE:- 0.68
Na = 137
K= 4.3
CL = 101
ECHO :-
EF :- 45 %
MILD HYPERTROPHIC LV WITH
DIASTOLIC DIMENSION OF 45 , AND
SYSTOLIC DIMENSION OF 28.
DILATED RV WITH DEPRESSED
SYSTOLIC FUNCTION ( TAPSE 14 mm )
TURBULANCE SEEN IN LPA WITH
CONTINOUS FLOW PPG 55 mm Hg
MOST LIKELY CONSISTENT WITH LPA
obstruction or MAy be PDA WITH
SHUNT REVERSAL C/W PROFILE
SHOWS CONTINOUS FLOW WITH
DAGGER SHAPE
PASP :- 75 mm Hg
MILD TO MODERATE TR WITH
SEVERE PH
PFO WITH RIGHT TO LEFT SHUNT
CARDIAC CT REPORT
SEVERE STENOSIS OF LUPV
SEVERE STENOSIS OF LPA ( NARROWEST
PART 2.4mm , TOTAL LENGTH 39mm
BIFURCATION ) FOLLOWED BY SEGMENT
STENOSIS , MULTIPLE SUB SEGMENTAL
BRANCH STENOSIS OF RPA
MPA =25m, RPA(PROX 17mm ) ,LPA ( PROX
21mm) ,
FIBROSIS OF LEFT APICAL PULMONARY LOBE
WITH CALCIFICATION , FIBROTIC BAND IN
RIGHT APICAL LOBE AND LOWER
PULMONARY LOBE
FIBROSIS B/L HILAR REGIONS
PROVISIONAL DIAGNOSIS
B/L SEVERE STENOSIS OF PULMONARY ARTERIES
PLAN
• RIGHT HEART CATHETERIZATION
• LEFT PULMONARY ARTERY STENTING , AND RIGHT PULMONARY ARTERY
BALOONING