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A 60 year male with valvular heart disease

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs



A 60 year old male farmer by occupation came to casualty with c/o shortness of breath since 2 years 
Pedal edema since 
Epigastric pain since 2 years
HOPI
Patient was apparently alright 2years back then developed sob which progressed to grade 3 sob nyha classification 
Pedal edema involving ankles upto knees
Pain in epigastric region since 2 years

Past history 
H/o an episode of pharyngitis 10 years back
Not  a known case of DM,HTN,ASTHMA,EPILEPSY,THYROID DISORDERS 

PERSONAL HISTORY-
Diet-mixed
Appetite-normal
B &B movements- regular
Sleep-normal
Addictions-  nil
GENERAL EXAMINATION-




Patient is conscious,  coherent, cooperative 
Moderately built and moderately nourished 
Oriented to time ,place and person
No signs of pallor,icterus,cyanosis,clubbing,koilonychia, lymphadenopathy 

VITALS AT ADMISSION:
Afebrile 
BP-110/60 mmhg
PR-68bpm
RR-18cpm





SYSTEMIC EXAMINATION-
CVS-
Inspection 
Shape of chest- symmetrical 
Trachea -central 
No scars ,sinuses ,dilated veins
JVP not elevated 
Palpation-
All inspection findings confirmed 
Trachea -central
Apex beat- left 5th intercoastal space midclavicular line

Auscultation -
Loud S1,S2  heard 
Early diastolic murmur 
RS-BAE+, Normal Vesicular breath sounds heard 
No added sounds
CNS-
No facial asymmetry ,all reflexes are normal
GIT 
No hepatosplenomegaly,no ascites

Investigations


 6min walk test-
Vitals before testing : 
PR 64 bpm
RR 28 cpm
BP 110/60 mmHg
SPO2 99% @RA
Distance covered: 191.25 meters
Duration: 6mins

Vitals after testing: 
PR 74 bpm
RR 34 cpm
BP 100/60 mmHg
SPO2 98%@RA




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