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2012-21199
HISTORY
Genral Information
Patient Name: E.T.D.
Date of Birth: March 17. 1976
Address: Meycauayan, Bulacan
Date: -
Data Source: Patient
Chief Complaint & ID: Ms. E.T.D. is a 42 y/o married Catholic female with a chief complaint of “parang
may tumutubo sa isang valve sa aking puso”
4 months prior to admission (May 2018): The patient had a 2D echocardiogram done in PGH, but
the files were corrupted so no results were observed.
On the day of admission (September 7, 2018): The patient had another 2D echocardiogram done in PGH,
and the results showed some growth in her mitral valve. Although the patient was asymptomatic, she was
admitted in the hospital and was given some antibiotics. She was initially given vancomycin but
developed chills after intake, so she instead began treatment of Ampicillin/Sulbactam with a dose of 500
mg and 200 mg, respectively, via IV every 12 hours.
Two weeks after admission (September 24, 2018): The patient got her tooth jacket removed since
it was speculated to be the cause of the infection on her mitral valve.
Cardiovascular Symptoms
na
Review of Systems
Head: No complaints of dizziness, headache or any head injury
Eyes: No complaints of hearing loss, tinnitus, ear ache, or ear discharge.
Nose: No complaints of congestion,discharges, bleeding, itching, or any pain.
Cardiovascular: -
Surgical -
Accidents/Injuries -
Medications -
Medicines: Her laboratory work-up showed dyslipidemia so she was given 1⁄2 dose
of Rosuvastatin? every night.
Vitamins: Previously taking Vitamin B-complex but was discontinued on July 2018
upon physician’s advice
Others -
2016: Consulted for a headache, located at the left occipito-parietal region. She was given
unrecalled antibiotics. No mention of another episode.
Incidental finding of scoliosis during x-ray, painful when doing the laundry.
Family Medical History
Other family relations: the patient cannot determine other history associated with siblings and other
family relations
Personal and Social History
OB score: G2P2
Alcohol intake: Drinks red wine on special occasions
Occupation: Housewife, used to clean rice and garlic (retired in 2016); now
tends to goats, does housework
.
PHYSICAL EXAMINATION
Vitals
Temperature: 36.7oC
Heart Rate: 75 bpm (manually counted, irregular rhythm)
O2 saturation: 99%
Problem List:
1. Slow heart rate
2. Near syncope (Dimming of vision + fatigue)
3. Chest pain
Differential Diagnosis
1. Slow heart rate
The normal heart rate, arising from the SA node, has been considered historically to
range from 60-100 beats per minute. (Homoud, 2017) The patient was referred to PGH by her
physician due to slowing of heart rate or bradycardia, and after performing Holter test. This
symptom may be associated with different cardiac conditions resulting in a reduced heart rate
such as Sinus Bradycardia, Atrioventricular heart block or dissociation, wandering atrial
pacemaker, Junctional (AV nodal) escape rhythms, and ventricular escape (UpToDate, 2018). On
history taking, non-cardiac conditions that cause bradycardia like being an athlete, taking
medications, and non-cardiac infectious diseases can already be ruled out.
To establish diagnosis, physical examination and electrocardiogram are necessary.
3. Chest pain
Chest pain may be associated with differentials Angina, Esophageal, GI, Biliary,
Pulmonary, Musculoskeletal, or functional. To differentiate these:
Since the patient’s chest pain is associated with drinking of water and is palliated by
burping, it is most probably esophageal in origin and is not associated with other symptoms
described previously.
References:
Benditt, D. (2018). Syncope in adults: Clinical manifestations and diagnostic evaluation. UptoDate.
Retrieved October 5, 2018 from UptoDate Offline Content.
Homoud, M. (2017). Sinus bradycardia. UptoDate. Retrieved October 5, 2018 from UptoDate Offline
Content.
Aherrera, J., Yu, M., Tingson, M., Gauiran, D., Duya, J., andBanzuela, E. (2018). IM Platinum (3rd. ed.).
Ward 3 Bed 38
Case: IE
History
Patient: E.T.D.
Age: 42
Date of Birth: March 17, 1976
Place: Meycauayan, Bulacan, originally from Isabella until age 17
Civil Status: Married with 1 child
Religion: Roman Catholic
Physical Exam
● Vitals: 36.7 ºC, 75 bpm (manually counted, irregular rythm), 99% O2 sat, BP 100/70 on
right arm
● (-) clubbing, cyanosis
● (+) bruise? Left forearm
● Pulses appreciated at left and right brachial, radial, dorsalis pedis & posterior tibial
arteries, 2+
● Popliteal pulses not appreciated
● (-) precordial bulge
● JVP: 3.9 cm from sternal angle of Louis; JVP increased to 6.5 from hepatojugular reflux
PMI: 6th ICS LAAL
Heave at PMI and 2nd ICS MCL
Irregular heartbeat
No thrills
Systolic Murmur heard at: 2nd ICS RPSB (faintest), 2nd-5th ICS LPSB, up to 6th ICS LAAL
Loudest at 2nd ICS RPSB, 6th ICS LAAL (conflicting); GRADE 3 since moderately loud (-Dan
Uy)
No carotid bruit
Palpatory BP
Auscultatory BP 100/70 (normal)
Cyanosis none
Clubbing none
Edema none
Pulses +2 left and right brachial, radial, dorsalis
pedis, posterior tibial
Popliteal pulse not appreciated
Aorta, renal, and femoral arteries ?
Pulsatile mass in abdomen none
Cutaneous ecchymoses Bruise on left forearm
Skin lesions none
Neck Exam
Precordial Exam
Differential diagnosis
Valvular heart disease
Mitral regurgitation (rule in: holosystolic murmur at LLSB)
Infective endocarditis (rule in: tooth infection)
Rheumatic heart disease (rule in: history of infection, history of mitral stenosis)
VSD (rule in: holosystolic murmur at LLSB, apical heave/LVH/displaced PMI)
Iatrogenic MR (rule in: previous PTMC)
Arrhythmic disorder (rule in: irregular heart beat/a-fib?)