Patient: ENRIQUE PROTT GERARDO

Dx:
• SEVERE MITRAL STENOSIS AHA D
• MILD MITRAL REGURGITATION
• MILD TRICUSPID REGURGITACION
• MILD PULMONARY REGURGITACION
• INACTIVE RHEUMATIC CARDIOPATHY
• PERMANENT ATRIAL FIBRILLATION
• HYPERURICEMIA

50-YEAR-OLD MEN'S PATIENT, THAT COMES FROM THE ADMISSION SERVICE, BORN AT
VERACRUZ CITY, AND LIVING IN TUXTLA GUTIERREZ CITY, MARRIED, JANITOR AS JOB,
JEHOVAHS WITNESS, O + BLOOD TYPE

PATHOLOGICAL BACKGROUND
CHRONIC DEGENERATIVE. DM2 DENIED, ATN DENIED
SURGICAL HISTORY: NEG
T RANSFUSIONS DENIED
NO CARDIAC HISTORY

PATIENT WHO PRESENTED REUMATIC FEVER AT 12 YEARS OLD, RECEIVING NON-SPECIFIED

ANTIMICROBIAL TREATMENT, WITHOUT FOLLOW-UP, IN JANUARY 2019, BEGINS WITH
PRESENCE OF PALPITATIONS WHILE SLEEPING, HE PRESENTED TO AND URGENT CARE
OFFICE AT HIS TOWN AT SEPTEMBER 2019, WHERE HE COMPLETES MEDICAL STUDIES. HE
PRESENTED WORSENING OF HIS DYSPNEA AND PAIN, WITH FUNCTIONAL CLASS GOING
FROM NYHA II TO NYHA III.
HE WAS PRESENTED IN MEDICAL SURGICAL SESSION AT DAY 20.06.2019 BEING ACCEPTED
FOR MITRAL VALVULAR REPLACEMENT AND EXCLUSION OF LEFT ATRIAL APPENDAGE.

HE DENIES TO RECIVE TRANSFUSION, SO HE WAS DISCHARGED FROM THE HOSPITAL FOR

NOT ACCEPTING TRANSFUSIONS AS AN INDISPENSABLE PREQUIRURGICAL
REQUIREMENT.

PATIENT AT THIS MOMENT WHO REFERS ASYMPTOMATIC, DIES CHEST PAIN, SYNCOPE OR
OTHER SYMPTOMATOLOGY.

PHYSICAL EXPLORATION 128/64 MMHG, 87 CR, RF 18, T 36º C

CURRENTLY ORIENTED IN PERSON, SPACE AND TIME, PSYCHOMOTRIC AGITATION, DOES
NOT VERBALIZE, ADEQUATE COLORATION OF TEGUMENTS, ISOCORICAL PUPILS, PRESENT
PHOTOMOTOR AND CONSEQUENTIAL REFLECTS, NECK SUPPLE, WITHOUT
LYMPHADENOPATHY OR THYROMEGALY, NO CAROTID BRUITS, LUNGS DIFFUSE, BILATERAL
CRACKLES THROUGHOUT LUNG FIELDS, NO WHEEZES, NO ACCESORY MUSCLE USE OR
CYANOSIS, NO EGOPHONYM NO TENDERNESSS TO PALPITATION, CARDIAC WITH REGULAR
RATE AND RHYTHM, WITH FIRST INCREASED NOISE, DIASTOLIC BLOW IN MITRAL FOCUS,
NORMOACTIVE BOWEL SOUNDS, SOFT, FLAT, NON-TENDER, AND NON-DISTENDED, NO
HEPATOSPLENOEGALY, LIVER SPAN APPROXIMATELY 10CM PERFORMANCE INTEGRAL
MEMBERS WITH ADDECUATE PULSES.

LABORATORY STUDIES
08.10.2019 GLU 90, UREA 28, BUN 13.1, CREA 1.21, NA 139, K 4.6, HB 18.5, HTO 55, PLA
327, LEU 8.1, NEU 3.66, LIN 3.36
07.15.2019 GLUCOSE 94, UREA 33, BUN 15.4M CREAT 1.1, NA 143, K 4.6, CL 103, COL 1.59,
TRI 96, HDL 47, LDL 93, VLDL 19.2, DHL 364, HB 17.7, HTO 51.9, PLA 310 , LEUCOS 7.6, NEU
3.7, LIN 3.19, INR 1.5

ELECTROCARDIOGRAM 05.30.2019. SINUSAL RHYTHM, CARDIAC RATE 75, AXIS 30

DEGREES, P 80MS, PR 120 MS, QRS 80 MS, QT 360 MS.

ECOCARDIOGRAM 06.17.2019
LEFT VENTRICLE NOT DILATED, CONCENTRICAL REMODELED (LEFT VENTRICLE MASS 63 GR
/ M2) WITHOUT CHANGES IN THE SEGMENTARY CONTRACTILITY, EJECTION FRACTION BY
SIMPSON 56%, DIASTOLIC DYSFUNCTION MODERATED, LEFT ATRIUM ARE DILATED ,
MYXOMATOUS THICKENING OF THE MITRAL LEAFLETS WITH MODERATE POSTERIOR
LEAFLET PROLAPSE, MILD MITRAL REGUGITATION, LIMITED OPENING,PLANIMETRY AREA
OF 0.9 CM2, GRADIENT MAX OF 12 MMHG, MEDIUM 5 MMHG, MAXIMUM SPEED OF 1.7
MSEG, TIME OF HEMIPRESION OF 200 MS, WILKINS SCORE 9 POINTS , MILD
REGURGITATION OF THE TRIVALVE AORTIC VALVE, WITH MILD THICKENING OF THE
LEAFLETS, WITHOUT REGURGITATION OR SIGNIFICANT GRADIENT FUNCTIONS, PSAP OF 36
MMHG, PT NORMAL, PULMONARY VALVE NORMAL, WITHOUT PERICARDIAC EFFUSION.

PATIENT ACCEPTED FOR MITRAL VALVULAR REPLACEMENT SURGERY, AND EXCLUSION OF

LEFT ATRIAL APPENDAGE.

DR. JESUS ZAIN CAMPOS LARIOS MAT 99150319 / DRA VANIA E. AYON MENEZ MAR
99237635