Cardiovascular Case Study

History of Present Illness

Patient is a 56-year-old female, referred to the cardiology clinic by her family physician for
increasing severe SOB. She denies angina pectoris. Symptoms first appeared 5 years ago
following an acute episode of viral bronchitis. At that time, the SOB was attributed to the
lung infection. However, symptoms continued to gradually worsen rather than improve.
Adult-onset asthma and emphysema have been ruled out by a pulmonologist. At this time,
the patient is experiencing severe SOB with mild activity. She has recently noticed swelling
in her feet, and her family physician has now diagnosed CHF, prescribed Digoxin, and
referred her for future diagnosis and treatment.

Past Medical History

Appendectomy at age 8. Rheumatic Fever at age 16. Three pregnancies, all children
delivered vaginally and are healthy. Left breast lumpectomy at age 45 with no
reoccurrence of malignancy.

Family and Social History

Patient drinks 1-2 alcoholic beverages weekly. She has never smoked, but husband smokes
one pack/day. She is a school teacher. No exposure to environmental toxins. Family
history is negative for heart disease. Mother died at age 26 from complication of childbirth.
Father died at age 60 from lung cancer. She has one sister, age 60, who is healthy except
for rheumatoid arthritis.

Physical Examination
PJT is mildly SOB sitting in exam room. HR is 153 bpm, rhythm is normal. BP is 180/90 in
left are while sitting. NO cyanosis is noted. Weight is within normal range, but she does
have noticeable edema in bilateral feet but not in her hands or face. Abdomen is mildly
distended with fluid, but not organomegaly is palpated. Chest auscultation reveals a
clearly audible heart murmur during ventricular contraction.

Diagnostic Tests
EKG; tachycardia at rate of 153 bpm but normal rhythm and no evidence of MI.
Transesophageal echocardiography is consistent with mitral prolapse with regurgitation
of blood into left atrium from left ventricle.

Diagnosis
Mitral valve prolapse and CHF secondary to rheumatic heart disease.

Plan of Treatment
Schedule patient for mitral valvoplasty with prosthetic valve

Please answer the following questions regarding this case study.

3/13/18
 You are to answer the questions in a word file and upload the file into the Assignment
Drop Box. This is an opportunity to see how Med Term will be used in realistic events in
the healthcare field. To answers some questions, you may need to use information from
other chapters, in a medical dictionary, or online. Also, be sure to list any sources you used
to gather your information.

1. Pick out at least five medical terminology words from the case study and dissect them
into their prefixes, suffixes and/or combining forms/word roots. Define each element and
then define the whole word. Hint: Look at bolded words.

Example: Arthritis Arthr(joint) itis(inflammation)

Whole word meaning: Inflammation of the joints

A. echo (repeated sound) cardio (heart) graphy (recording)

B. valvo (valve) plasty (surgical repair)

C. tachy (rapid) cardia (heart)

D. organ (organ) omegaly (enlargment)

E. append (appendis) ectomy (removal)

2. Name and define the following abbreviations used in this medical record:

SOB- Shortness of breath- not being able to get enough air

CHF- Congestive heart failure- condition that effects the pumping power of your heart
muscle

bpm- beats per minute- how many times your heart beats per minute

BP- blood pressure- the force of your blood pushing against the walls of your arteries

3. Name and define the symptom the patient denies having.

Answer: angina pectoris- chest pain caused by insufficient blood flow to the heart.

4. The physician’s diagnoses is asthma and emphysema.

5. Name and define the surgical procedure that the patient is scheduled to have done in her
plan of treatment.

Answer: valvoplasty- treatment to open a narrowed heart valve.

3/13/18