VELASQUEZ, ZADKIEL F.

2012-21199

HISTORY
Genral Information
Patient Name: E.T.D.
Date of Birth: March 17. 1976
Address: Meycauayan, Bulacan
Date: -
Data Source: Patient

Chief Complaint & ID: Ms. E.T.D. is a 42 y/o married Catholic female with a chief complaint of “parang
may tumutubo sa isang valve sa aking puso”

History of Present Illness

4 years prior to admission (2014): The patient experienced symptoms of heaviness and pressure
on the left side of her chest while she was in Zumba class. Such symptoms began to occur each time she
would engage in vigorous activities such as exercise and household chores. Her symptoms improve upon
rest. She would grade the quality of the discomfort as 6 out of 10. The feeling of heaviness did not radiate
to any other region. Symptoms did not happen at any particular time of the day. She went to a local
hospital in Bulacan for a consult, then sought out a second opinion in the Philippine General Hospital. In
PGH, she was diagnosed with mitral valve stenosis and was given the following medications: Metoprolol,
Losartan, and injectable Penicillin. She took the medication for two years.
2 years prior to admission (2016): The patient was advised to undergo Percutaneous
Transvenous Mitral Commissurotomy (PTMC) and was admitted to PGH on December 20, 2016. She
was discharged on December 23, 2016 and was given the following medications: Carvedilol, Digoxin,
Warfarin, and injectable Penicillin.

4 months prior to admission (May 2018): The patient had a 2D echocardiogram done in PGH, but
the files were corrupted so no results were observed.
On the day of admission (September 7, 2018): The patient had another 2D echocardiogram done in PGH,
and the results showed some growth in her mitral valve. Although the patient was asymptomatic, she was
admitted in the hospital and was given some antibiotics. She was initially given vancomycin but
developed chills after intake, so she instead began treatment of Ampicillin/Sulbactam with a dose of 500
mg and 200 mg, respectively, via IV every 12 hours.

Two weeks after admission (September 24, 2018): The patient got her tooth jacket removed since
it was speculated to be the cause of the infection on her mitral valve.

Cardiovascular Symptoms
na
Review of Systems
Head: No complaints of dizziness, headache or any head injury



Eyes: No complaints of hearing loss, tinnitus, ear ache, or ear discharge.

Ears: No complaints of loss or change of vision, abnormal discharges, pain,

redness, flashing lights. The patient does not use glasses or contact lenses



Nose: No complaints of congestion,discharges, bleeding, itching, or any pain.

Throat: No complaints of dental caries, bleeding gums, sore tongue, mouth

sores, dry mouth, sore throat, hoarseness of voice, thrush, enlarged lymph nodes,
neck pain, stiffness, or swallowing. No palpable masses.

Respiratory: No complaints of cough, dyspnea, orthopnea, or paroxysmal

nocturnal dyspnea.

Cardiovascular: -

Gastrointestinal: No complaints of abdominal pain, heartburn, vomiting, diarrhea,

constipation, change in appetite, change in bowel habits, flatulence, rectal bleeding
melena, hematochezia

Genitourinary: No complaints of dysuria, polyuria, or hematuria. The color of

urine was noted to be clear yellow and noted that she does not have incontinence.

Musculoskeletal: No complaints of edema, joint pains, trauma, gross deformities

Integumentary: No obvious signs of rashes, sores, blisters, or growths.

Past Medical History

Surgical -

1995: Delivery of first child via caesarean section.

1996: Right partial thyroidectomy to remove goiter.

1999: Delivery of second child via caesarean section.



Accidents/Injuries -

No significant accidents or injuries noted

Medications -
 Medicines: Her laboratory work-up showed dyslipidemia so she was given 1⁄2 dose
of Rosuvastatin? every night.

Vitamins: Previously taking Vitamin B-complex but was discontinued on July 2018
upon physician’s advice

Supplements: There were no other herbal or food supplements taken.



Others -

2016: Consulted for a headache, located at the left occipito-parietal region. She was given
unrecalled antibiotics. No mention of another episode.

Incidental finding of scoliosis during x-ray, painful when doing the laundry.



Family Medical History 


Mother: Hypertension, diabetes

Father: Hypertension, asthma

Other family relations: the patient cannot determine other history associated with siblings and other
family relations



Personal and Social History 


OB score: G2P2



Alcohol intake: Drinks red wine on special occasions


Tobacco use: Never; husband smokes outside home

Illegal Drug use: Never.

Occupation: Housewife, used to clean rice and garlic (retired in 2016); now
tends to goats, does housework

.

Travel: To Batangas (hometown) every year



Education: High school graduate




PHYSICAL EXAMINATION

Vitals 


Temperature: 36.7oC



Heart Rate: 75 bpm (manually counted, irregular rhythm)

O2 saturation: 99%

Blood pressure: 100/70 mmHg on right arm

Problem List:
1. Slow heart rate
2. Near syncope (Dimming of vision + fatigue)
3. Chest pain

Differential Diagnosis
1. Slow heart rate
The normal heart rate, arising from the SA node, has been considered historically to
range from 60-100 beats per minute. (Homoud, 2017) The patient was referred to PGH by her
physician due to slowing of heart rate or bradycardia, and after performing Holter test. This
symptom may be associated with different cardiac conditions resulting in a reduced heart rate
such as Sinus Bradycardia, Atrioventricular heart block or dissociation, wandering atrial
pacemaker, Junctional (AV nodal) escape rhythms, and ventricular escape (UpToDate, 2018). On
history taking, non-cardiac conditions that cause bradycardia like being an athlete, taking
medications, and non-cardiac infectious diseases can already be ruled out.
To establish diagnosis, physical examination and electrocardiogram are necessary.

2. Near-syncope (Dimming of vision + fatigue)

Syncope is a transient loss of consciousness resulting in a loss of postural tone.
Presyncope, or near-syncope, is essentially a manifestation of the same symptoms that might
lead to syncope in the same individual at other times, or may in other patients never lead to true
loss of consciousness. (Benditt, 2018) Possible causes of this condition are generally grouped
into four major categories: Reflex syncope, Orthostatic syncope, Cardiac arrhythmias, and
 structural cardiopulmonary disease. (Benditt, 2018) In this case, we need to distinguish whether
the near-syncope is actually vasovagal form of reflex syncope or cardiac cause of syncope.
To differentiate Vasovagal form from cardiac cause, the following symptoms are looked
into: lightheadedness, feeling of being warm or cold, sweating, palpitations, nausea or non-
specific abdominal discomfort, visual “blurring occasionally proceeding to temporary darkening or
“white-out” of vision, a diminution of hearing and/or occurence of unusual sounds, and pallor
reported by onlookers. When these prodromal symptoms are felt, syncope is associated with
vasovagal form (Brenditt, 2018).
When patients have no warning symptoms, with a rapid restoration of full consciousness
after, cardiac causes are considered (Aherrera, Yu, Tingson, Gauiran, Duya, Banzuela, 2018).
Complete physical examination and ECG are necessary to determine the cause.

3. Chest pain
Chest pain may be associated with differentials Angina, Esophageal, GI, Biliary,
Pulmonary, Musculoskeletal, or functional. To differentiate these:

Differential Provocative Palliative Timing Other

Angina Effort Rest, Nitrates Min. Coronary
disease risk
factors

Esophageal Feeding, exercise, Burping, Drinking, Min. Angina-like

supine position Nitrates

GI Fasting Food, antacids Min. Epigastric Pain

Biliary Feeding Spontaneous, Rx Min. Colicky
Pulmonary/ Respiration, cough Analgesics Variabl Cough and
Pleural e fever

MSK Posture, motion, Analgesics Variabl Tietze’s

pressure e Syndrome

Functional Stress Relaxation Variabl Da Costa’s

e Syndrome

Since the patient’s chest pain is associated with drinking of water and is palliated by
burping, it is most probably esophageal in origin and is not associated with other symptoms
described previously.

References:

Benditt, D. (2018). Syncope in adults: Clinical manifestations and diagnostic evaluation. UptoDate.
Retrieved October 5, 2018 from UptoDate Offline Content.
Homoud, M. (2017). Sinus bradycardia. UptoDate. Retrieved October 5, 2018 from UptoDate Offline
Content.

Aherrera, J., Yu, M., Tingson, M., Gauiran, D., Duya, J., andBanzuela, E. (2018). IM Platinum (3rd. ed.).

PAST MEDICAL HISTORY

The patient contracted mumps at a young age, but could not remember at what specific age and the details. She had measles when
she was 12 years old. The patient developed a serious tooth infection when she was 8 years old, and it grew into an abscess that
ruptured. The infected tooth was not removed, and she was only treated with herbal remedies, particularly “tapal.” Prior to
consultation, she was only admitted to the hospital when she underwent PTMC in PGH. She has no history of allergies, except
when she developed chills upon administration of vancomycin, which was discontinued.
FAMILY MEDICAL HISTORY
The patient’s family has no history of tuberculosis, diabetes, asthma, cancer or stroke. The patient’s father died of hypertension, and
currently, her two sisters are taking maintenance medication for hypertension.
PERSONAL AND SOCIAL HISTORY
The patient traveled to Dubai and worked as an OFW when she was 17 years old. She came back to the Philippines when she was
21 years old because she got pregnant abroad. The patient currently lives in a 3-story house in a private area in Meycauayan,
Bulacan with her husband and nephew. Her husband works as a receptionist in a condominium, while she rents apartments and
garners some income from her family’s farm in Isabela. She has one daughter, a 21-year old currently living in a dorm in Espana,
Manila. The patient never smoked, but was a social drinker (1x/week, 1-2 bottles) until she stopped 9 years ago (33 years old). The
patient denied illicit drug intake and IV drug use. No other vices were reported.
OBSTETRIC AND GYNECOLOGIC HISTORY
The patient’s menarche was when she was 14 years old. Patient has an obstetric score of G2P1(1,0,1,1). She had two pregnancies:
the first resulted in a miscarriage while the second pregnancy was carried to full term. She gave birth at home in Bulacan to a
healthy, 6.25-pound baby girl. The patient does not experience any pelvic or coital pain and does not have any abnormal vaginal
discharge.

Ward 3 Bed 38
Case: IE

History
Patient: E.T.D.
Age: 42
Date of Birth: March 17, 1976
Place: Meycauayan, Bulacan, originally from Isabella until age 17
Civil Status: Married with 1 child
Religion: Roman Catholic

History of Present Illness:

September 7, 2018
Other symptoms: irregular palpitations

Physical Exam
● Vitals: 36.7 ºC, 75 bpm (manually counted, irregular rythm), 99% O2 sat, BP 100/70 on
right arm
● (-) clubbing, cyanosis
● (+) bruise? Left forearm
● Pulses appreciated at left and right brachial, radial, dorsalis pedis & posterior tibial
arteries, 2+
 ● Popliteal pulses not appreciated
● (-) precordial bulge
● JVP: 3.9 cm from sternal angle of Louis; JVP increased to 6.5 from hepatojugular reflux
PMI: 6th ICS LAAL
Heave at PMI and 2nd ICS MCL
Irregular heartbeat
No thrills
Systolic Murmur heard at: 2nd ICS RPSB (faintest), 2nd-5th ICS LPSB, up to 6th ICS LAAL
Loudest at 2nd ICS RPSB, 6th ICS LAAL (conflicting); GRADE 3 since moderately loud (-Dan
Uy)
No carotid bruit

Blood Pressure and PVS

Palpatory BP
Auscultatory BP 100/70 (normal)
Cyanosis none
Clubbing none
Edema none
Pulses +2 left and right brachial, radial, dorsalis
pedis, posterior tibial
Popliteal pulse not appreciated
Aorta, renal, and femoral arteries ?
Pulsatile mass in abdomen none
Cutaneous ecchymoses Bruise on left forearm
Skin lesions none

Neck Exam

Jugular venous pressure 3.9 cm (CVP = 8.9 cm)

Hepatojugular reflux Negative (JVP increased to 6.5 cm)
Carotid pulse No carotid bruit
Brisk and tapping

Precordial Exam

Precordial bulge none

 PMI 6th ICS LAAL (displaced laterally and
downwards)
Heaves PMI (6th ICS LAAL)
2nd ICS MCL
Thrills none
S1 Heard best at ?
S2 Heard best at ?
No splitting
Murmurs Grade 3/6 holosystolic murmur loudest
at 6th ICS LAAL in left lateral decubitus
position
Also heard at 2nd ICS RPSB, 2nd-5th
ICS LPSB
Heart rate 75 bpm, irregular

Differential diagnosis
Valvular heart disease
Mitral regurgitation (rule in: holosystolic murmur at LLSB)
Infective endocarditis (rule in: tooth infection)
Rheumatic heart disease (rule in: history of infection, history of mitral stenosis)
VSD (rule in: holosystolic murmur at LLSB, apical heave/LVH/displaced PMI)
Iatrogenic MR (rule in: previous PTMC)
Arrhythmic disorder (rule in: irregular heart beat/a-fib?)