ALCARAZ CLINIC – Internal Medicine

285 JP Laurel St., Nasugbu, Batangas

CLINICAL ABSTRACT

Identifying Information

Rodelma Villaveza, 41/F, from Talangan, Nasugbu, Batangas, came in last December 7, 2015 for easy fatigability
x 1 week.

History of Present Illness

December 2015 1st week worsening easy fatigability for one week, with associated chest pain and
paroxysmal nocturnal dyspnea
Advised 2d echo with DS during that time, given meds and advised surgical options

Past Medical History told to have heart disease c/o another private MD in 2013, on Digoxin 0.25mg tab OD prior to
this consultation

Family Medical History heart disease - mother

Personal and Social History sigle with 1 child, sari-sari store owner , G1P1 (1001); allegedly with irregular menses
even before

Physical Examination
Awake , conscious, coherent, not in respiratory distress
BP 130/80 HR 89 irregular RR 22 T afebrile
Pink conjunctivae, anicteric sclerae, slight NVE, no CLAD, no TPC
ECE, occasional R basal crackles
AP, DHS, NR, irregularly irregular rhythm, (+) murmurs appreciated, MR and AR grade 3/6, apex beat at 6th ICS
LMCL
Soft abdomen, NABS, no palpable masses, minimal tenderness over the RUQ area
No cyanosis, trace grade 2 edema, sl. pale nailbeds, full and equal pulses

LABS:
2D echo with DS RHD; severe mitral sclerosis with moderate MR; moderate AR +; mild TR; mild pulmonary HPN;
normal LV with adequate contractility and systolic function; normal RV dimension with adequate
contractility; with signs of pressure and volume overload; EF 60; LVEDD 4.3

Present Working Impression

Rheumatic Valvular Heart Disease, in congestive heart failure functional Class 1
Management:
Warfarin 2.5mg tab 1 tab Mon-Sat
Sumapen V K 250mg cap BID
Furosemide 40mg tab OD
Metoprolol 50mg tab BID
Enalapriln 5mg tab OD
 Advised surgical options; advised regular monitoring of PT INR; last PT INR was 1/26/16 (no follow up since
then)

Prepared by:

John Dennis Alcaraz, MD, FPCP

Internal Medicine
License # 107562