AF with FVR and severe MS

 

A 55 year old female ,who is an agricultural labourer came to the casualty around 7pm with the complaints of 

shortness of breath since 10 days , increassed from doing minimal works to at rest since 2 days

C/ O palpitations since 10 days

C/ O decreased urine output since 3 days

Anasarca since 3 days

Nausea and vomiting since 10 days

HOPI:

Pt was apparently asymptomatic 10 days ,when the patient had fever for 5-6 days,not associated with cough, cold,loose stools, decreased on medication with paracetamol,after which the patient had shortness of breath even at rest for which she stopped going to the fields,this was associated with palpitations,feeling of nausea and 1 episode of vomiting and light headedness, then she had a decrease in urine output since 3 days , did not pass stools , abdominal distension,pedal edema , for which she was brought to the hospital.

Past history:

Not a k/c/o diabetes, hypertension,ckd ,cad.

Similar complaints of SOB and palpitations 5 years back ,when she was treated conservatively for 1 week and did not use medication since then.

Personal history:

Appetite decreased

Urine output decreased

O/E: 

Pt is drowsy but arousable

Peripheries- cold to touch

Sweating decreased

PR- irregularly, irregular ;160-170 bpm

Apex beat to pr

Bp- 60 mmHg sbp

CVS- s1, s2+ muffled

BAE - Diffuse bilateral fine crepts present.

Investigations: 

Hemogram:

Hb: 14.4

TLC: 12,600

PLT: 1.50

CUE:

Alb: +3

Sugar: trace

RFT:

Urea:86

Creat: 1.3

Na- 130

K- 4.5

Cl- 90

Provisional diagnosis:

Valvular AF with FVR ( severe mitral stenosis)

Moderate ascites with HFrEF 

With ? Denovo DM type 2.

AS pt was unstable,drowsy and ecg showing A-Fib , DC SHOCK was given (150-360 J ) three times after sedating patient with midazolam.

Rate decreased to 130 BPM . Rythm remained irregular.

Echo was done later which showed poor lv systolic function and severe MS . Dialted ra ,rv and la and pah with severe tr .

Rate control would be an ideal strategy for a valvular AF , as its most likely to be a persistant AF / chronic AF .

Rhytm control isn't done in chronic AF , as there is risk of thrombo-embolism and stroke.

-Inj Lasix 40 mg iv stat was given 

-Pt was Intubated and put on Mechanical ventilator.

Pt was put on inotropic support with nor adrenaline and dobutamine . Still Bp was not recordable.

Next day early morning , in view of absent central pulse CPR was started and 8 Cycles of cpr was done . Still pt couldn't be revived and declared death .

Immediate cause of death - cardiogenic shock secondary to hfref and severe MS.

? Persistant AF 

Antecedent cause - severe ms (? Secondary to RHD ) .