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No difficult terms

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1) 45 year old man - middle aged citizen, the immune system of the patient is towards weakening condition, have high risk of getting diabetes, hypertension and other medical illness.

2) Admitted to the hospital - Meaning that he has a serious or life-threatening problem. So, the patient needs to stay at the hospital for appropriate care & treatment.Need further investigation in order to diagnosis any possible disease + monitoring patient condition.

3) 2 week increasing shortness of breath (dyspnea) and fatigue - Left sided heart failure, Congested pulmonary vasculature, Fluid enters into alveolar space, O2 interfere 02 exchange (Tissue hypoxia) SOB, Progressive Shortness of breath and cause dyspnoea at rest & lying down, pulmonary oedema

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1. bilateral leg swelling - both of the leg is swollen, due to systemic condition (heart failure, kidney, liver- hypoalbunemia, lung), Pulmonary edema

2. frothy sputum - mucus that contain bubble and is foamy due to fluid accumulate in the lung

3. Hyperlipidemia - high level of lipids in the blood including cholesterol and Triglyceride

4. Hypertension - BP against artery elevated (high BP)

5. squeezing chest pain - compressing on the chest

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1. breathlessness on walking, now breathless even at rest - stable angina led to unstable angina, worsening of the dyspnea from class 3 to class 4

2. bilateral leg swelling - both of the leg is swollen, due to systemic condition (heart failure, kidney, liver- hypoalbunemia, lung), Pulmonary edema

3. required three pillows to sleep as his breathlessness becomes worse on lying down - SOB, dyspnea, prop up position

4. coughing pinkish frothy sputum- sign of pulmonary edema, rule out TB, infection, pneumonia, high hydrostatic pressure causing leakage of blood into alveoli

5. no squeezing chest pain with radiation - rule out MI

6. has hypertension and hyperlipidaemia for the past ten years

7. smokes 20 cigarettes per day for the last 25 years - dust or carbon monoxide exposure

8. works as a lorry driver - dust or carbon monoxide exposure

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crepitations- crackle sound- abnormal when heard using stethoscope- present of fluid

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hypokinetic inferior segments- decrease contraction of the inferior wall of the heart

sinus rhythm- heart beating normally

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1. HISTORY TAKING

SOCRATES

site

onset - is it persistent, all the time, or during night only, or worsening in the morning, is it the first time, berapa episodes dah

characteristic

radiation

associated symptoms - wheezing- COPD, night sweating - TB, dizziness- anemia, cough- TB, pneumonia, hemoptasis -TB,

time - during exercise or sleeping, morning and night - asthma

exacurbating factors- relieving factors, apa yang buat untuk relieve, medications ( ex - GTN )

severity - class 1- blh buat activity lagi, class 2 - buat activity baru sakit - climbing, class 3- biasa biasa pun dah penat, class 4 - berehat pun penat

past medical history- medical illness-diabetes, hypertension, asthma, COPD, CAD, CKD,

past surgical history - heart op,

social history - smoking, alcohol, diet history- strict vegetarian, vege ke tak, pekerjaan- chemicals exposure, dust exposure(asbestos)- risk factor for lung cancer

fam history - ada tak heart attack,

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CARDIOVASCULAR SYSTEM - IHD-MI, angina, ACS, heart failure, endocarditis

respiratory system - COPD, asthma, pneumonia, PE,

endocrine system - hyperthyroidism,

blood disorder - anemia

others - OSA (obstructive sleep apnea), obesity

metabolic causes - diabetic ketoacidosis (DKA)

congestive cardiac failure:

dyspnea

orthopnea

bilateral leg swelling

pinkish frothy sputum

fatigue

underlying hypertension and hyperlipidemia for 10 years

smoking 20 cigarettes per day for 25 years

1. distressed, high BP, high RR, high HR, pale and sweaty, low O2- restless

2. Bilateral pitting oedema up to the knees - heart failure

3. jugular venous pressure was raised at 7 cm- fluid overload right heart failure

4. apex beat was at the 6th intercostal space at the mid-clavicular

line- cardiomegaly

5. crepitations heard over the posterior lung bases posteriorly- indicate pulmonary oedema

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PHYSICAL EXAMINATION

1. vital sign - high BP, high HR, high RR (tachypnea), low Oxygen saturation (below 95), normal temperature

2. Examine CVS - palpate jugular vein and pulse, auscultate, listen to S1 S2 and any abnormal sound (murmurs) sign of valvular disease, palpate for edema either pitting or non-pitting

3. Respiratory system - check for rise of chest either symmetrical or not, palpate for trachea deviation, percussion resonance, Auscultate low part of the lung: reduce breath sound bcs of fluid accumulation

4. abdominal examination- Palpate for any organomegaly

INVESTIGATION

1. FBC

2. liver profile, renal function test

3. ECG

4. chest X-Ray - blunted of the lung due to presence fluid bi vessel

5. Echocardiogram - ejection rate

6. Angiogram

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1. distressed, high BP, high RR, high HR, pale and sweaty, low O2- restless 4.

2. Bilateral pitting oedema up to the knees - heart failure

3. jugular venous pressure was raised at 7 cm- fluid overload right heart failure

4. apex beat was at the 6th intercostal space at the mid-clavicular

line- cardiomegaly

5. crepitations heard over the posterior lung bases posteriorly- indicate pulmonary oedema

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low Na+ - dehydrate, fluid accumulation

high TG, high TC, high LDL, - due to hyperlipidemia for the past 10 years

low HDL- cardiovascular disease

left ventricular hypertrophy- wider QRS, ST depression, tall R wave, deep S wave, T wave inversion

Q waves in the inferior leads- indicate previous inferior infarction

left ventricular hypertrophy and hypokinetic inferior segments

(ECHOCARDIORAM) ejection fraction was 41%- low, (Normal men - 52 to 72%)

features of pulmonary oedema, congestive heart

failure secondary to hypertension

previous myocardial infarction

oxygen- short term

diuretics- short term, route of administration IV

vasodilators, nitrates- short term

ACE inhibitors- hypertension

beta-blockers- long term, CCF and Hypertension

fluid and salt restriction of 1 liter a day- long term

reduce of workload of the heart

follow-up in 2 months

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LEARNING ISSUES CVS CASE 2 with suggested activities