Severe MS AND HEART FAILURE. ?ACUTE PE

 A 60 year old woman presented with the complaints of 

Dyspnea at rest since 15 days

Left lower limb swelling upto knee since 10 days

Reduced urine output since 10 days

A 60 year old woman who used to work as a farmer 3 years back, mother of 5 children (3 daughters and 2 sons - 1 son expired, patients attendant reluctant to discuss the cause) presented to the casualty with the complains of dyspnea on exertion since 1 year. 1 year back she visited Osmania hospital for these complaints after which she has been put on medications which she has been using on and off (not documented). Since the past 4 months she has been experiencing dyspnea at rest on and off, whenever she experiences dyspnea she visits a hospital, takes medication and then stops taking them.

Since the past 15 days she has been experiencing dyspnea at rest and 10 days back she has had a trauma to her right 2nd toe after which she developed left lower limb swelling along with reduced urine output. She was taken to a local hospital where she was told that she developed left lower limb cellulitis.

Pallor+

PR - 150bpm; irregular,low volume

BP - 100/60mmhg

RR - 27cpm

Spo2 - 96% on Room Air 

Cvs - 

JVP raised

Parasternal heave +

Palpable P2

Visible apex beat

Apex beat in 6th ICS , 1cm lateral to MCL

Epigastric pulsations +

On auscultation - Loud S1 +

S2 split +

Conversation in online elog group : 

Ecg findings: KV

Absent p waves with heart rate of 150bpm

T wave inversions in V3 to V6 chest leads and poor R wave progression.

Non ST elevation myocardial infarction with Atrial fibrillation

Hod sir : 

 However her left lower limb DVT and pulmonary hypertension is uncannily similar to yesterday's admission who died today with suspected pulmonary embolism.

 Severe pulmonary hypertension is the most prominent finding and the lung appears normal so two differentials of chronic left ventricular failure and pulmonary embolism remain

Mitral stenosis looks prominent although could have stayed for some more time in the para sternal long axis view for a better delineation 👍

 KV : Hockey stick sign of thickened mitral valve visible on echo sir  and dilation of all four chambers with global hypokinesia.

 TREATMENT GIVEN : 

1) TAB METXL 25 mg /PO/STAT.

2) INJ LASIX IV INFUSION@ 4ml/hr.

3) TAB ECOSPRIN AV (150/75 MG) OD.

4) INJ HEPARIN 5000 IU IV STAT.

5) INJ PAN 40 mg Iv od

6) MONITOR VITALS 2 nd hrly