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DR. MUAZZAM HASAN DR.

MOHAMMAD RASHID

   

Name Age Sex Address

: Salman : 18yrs : Male : S/O Aftab R/O Jamal pur, Aligarh

     Diagnosis : Mitral stenosis with pulmonary hypertension CADS C/I D.S : 33583/13 : Prof M.O.O.Beg/Dr Azim Hasan : 26/11/13 : 4/12/13 .H.A D.

Progressive breathlessness : 10 years Recurrent cough with sputum : 1 year Palpitations (on and off) : 1 month .

Patient also had history of recurrent cough which was associated with sputum for last one year. The difficulty progressed gradually over time. .According to the patient he was apparently well 10 years back when he developed difficulty in breathing during brisk walking and running. and presently he was even unable to perform his daily activities due to breathlessness.

He was diagnosed as a case of mitral stenosis and was to J.C for further management.N.M. . For these complaints.Patient also had episodes of undue awareness of heart beat on and off for the last month. patient consulted a local private practitioner.

There is no H/O  vertigo Unconciousness       Hemoptysis Pink frothy sputum Orthopnoea Paroxysmal nocturnal dyspnoea Hoarseness Abdominal distension or pain .

HTN.normal bladder .normal appetite .decreased Family History – nothing significant Anaesthesia history Nil – .decreased bowel . Treated for pneumonia – 8yrs back No H/O DM. Personal History sleep .Past History – ATT – 10 yrs back. Patient or attendants do not recall history of fever with sore throat and joint pain in childhood.

25 mg od Tab lacilactone 20mg bd Started by roc cardiology from 26/11/2013 .Tab digoxin 0.

 The patient is a young male of average built. General condition – fair Pallor – IcterusClubbingCyanosis Lymphadenopathy Pedal edema ABSENT + . sitting comfortably and well oriented in time . place and person.

R Temp :20/ min : afebrile . :104/64mm of Hg R.P. low volumic) B.Vitals: Pulse rate :86/min(regular.

No adventitious sounds. SYSTEMIC EXAMINATION – RESPIRATORY SYSTEM  B/L equal air entry. Vesicular breath sounds. .

Inspection precordium normal in shape. no dilated veins Palpation apex beat at 5th ICS mid axilliary line no heave or thrill Auscultation loud S1 mid-diastolic murmur present( best at apex) early systolic murmur present .

Intact .Normal Cranial nerves Reflexes GCS . place and person.Intact -15/15 No sensory or motor deficit. .CNS       Patient well oriented with time. Higher functions .

P.Vitals: Pulse rate :92/min B. R.R :90/54mm of Hg :20/ min Temp : afebrile  .

   Dyspnea NYHA -III Chest pain(on exercise) Palpitations present present present       Pedal edema Vertigo Convulsions Cough Addiction Allergy 16 absent .

     Mouth opening MP Neck movement Teeth : Adequate : MP I : Adequate : No false or loose tooth Weight : 35kg .

No adventitious sounds CVS S1 loud diastolic murmur present early systolic murmur present . Vesicular breath sounds.Chest – B/L equal air entry.

6 mg% S. NA S.K : 134 : 4.   Hemoglobin TLC DLC : 11.1 gm% : 10600 cells/mm3 : P70 L25 Mxd5      Blood Sugar (R) : 115 mg% Blood Urea : 46mg% Serum Creatinine: 1.1 .

 Xray chest - .

6cm2 RA/RV dilated TR present (severe) EF = 66% .ECG P-mitrale in several leads      Severe mitral stenosis with sever PHTN MVA= 0.

 Kindly continue tab digoxin as adviced.  Kindly get a a morning S.ADVICE :  Pt may be taken up for surgery.  kindly stop tab lacilactone one day prior to surgery.25 mg HS night before surgery.  Tab Alprazolam 0. . K+ on the day of surgery and bring to OT.  NPO X 8hrs prior to surgery  Kindly arrange for GA  Kindly arrange for Blood as per surgical losses.

ronchi present : WNL .Date : 04/12/13 Operation : Mitral Valvotomy PREOPERATIVE VITALS :   PR BP : 108/min : 96/64 mm of Hg   Chest CNS : B/L wheeze.

Fentanyl 4 mg iv 50 ug iv . ondensetron Inj.TECHNIQUE : under GA IV access in Rt hand All monitors attached. PREMEDICATION : Inj.

. Inj. IPPV. OTI done with CETT (pvc) of size 6. Relaxed with inj.5 mm Maintained with Oxygen . Thiopentone 200+50 mg iv. succinylcholine 75 mg iv.     Pre oxygenation with 100% oxygen 5mins. Induced with inj. Vecuronium.Nitrous oxide .

TIME 09:30 am PR 98 BP 104 SPO2 96 IVF NS1 IVD REMARKS 09:45 am 10:00 am 10:15 am 10:30 am 10:45 am 94 86 88 84 82 96 90 96 98 102 88 90 96 97 97 BLOOD Inj fentanyl 30ug ETCO2=45 CVP= 35 ETCO2=46 Valve dilated CVP= 30 11:00 am 11:15 am 79 80 96 98 99 99 CVP=28 ETCO2=42 .

POSTOPERATIVE EXAMINATION : Vitals : PR – 84 /minute BP – 102/65 mm Hg Recovery: satisfactory Reflex: WNL Respiration: regular. adequate tidal volume GCS : 15/15 PUPILS –NSNR .

.Patient was extubated Post operative advice: NPO TFO Moist O2 inhalation Nurse in propped up position Good analgesia Patient shifted to ICU for post op monitoring and then shifted to ward second day under satisfactory condition.

THANK YOU .