Patient Case Study Mrs. J.A

History of Presenting Complaint 59 yo female Biprosthetic AV replacement CABG x2 (Last thurs – 5 days post-surgery) Release from ICU on Monday, recovering well Stage IV dyspnoea: SOB at rest First presentation of problem difficult to determine the patient has a mild intellectual disability

Past History IHD, HTN, Hypercholesterolaemia, AS, intellectual impairement, OA No previous hospital admissions (apart from wisdom teeth) Social H(x): Retired, lives in supportive care, nil smoking/ alcohol history, no drugs

Cardiovascular Risk-factors Unmodifiable – Age – Gender – Family Hx Modifiable – Sedentary lifestyle – Smoking – Diabetes mellitus – Diet – Hypercholesterolemia – Hypertension

Systems Review (on presentation) Syncope Angina Fatigue Edema- Denied ankle swelling (present on examination) Dyspnoea- Excertional dyspnoea (No orthopnea or PND) Palpitations – frequency 3-4 hours “Cramps’ in the legs – intermittent claudication??

Medications Paracetamol Pantoprazole (PPI) (proton pump inhibitor) Cephazolin (1 st generation cephalosporin) Aspirin Heparin Ezetimibe (cholesterol GI absorption inhibitor) Felodipine (Ca channel blocker) Lipitor (Atorvastatin calcium, HMG-CoA reductase inhibitor) Meloxicam (selective COX-2 inhibitor) Monoplus (Fosinopril sodium + hydrochlorothiazide) (ACE + Diuretic)

Examination General Inspection Normal diet, nil walking aids, well, no monitors, IV in left hand, multiple IV puncture sites, site of removal of central line Patient appears generally well, overweight women, mildly impaired mental state Surgical scar central thoracic healing well, nil pain Drains & temp pacemaker removed this morning Hands Hands – clubbing, nil other Pulse – 65bpm, BP 110/70, Temp 37.6 (afebrile) No RR/RF delay Face Nil – face Nil carotids JVP normal Chest Soft ejection systolic murmur aortic region radiating to back Lung field clear Nil other sounds, vocal resonance etc normal Abdomen No organomegaly Legs Pitting odema to ankle

Investigations Bloods - all normal, except prolonged INR-2.6 (0.8–1.2) & decreased Hb-96 (anaemia of chronic disease) Chest X-ray - see online URL Angiograms - see online also ECG - sinus rhythm, normal