My patient is 38 years old Malay women from Kota Bharu Kelantan.

She is admitted on 13 December,

C/c : my patient complained of bilateral leg swelling with SOB 1 week prior to admission

HOPI: My patient with underlying pulmonary embolism and DVT (diagnosed 1 year ago) presented
bilateral leg swelling and SOB 1 week prior to admission. The swelling is painless (no preceding event
such as car accident, surgery, or prolonged immobilization). She told that she had difficulty in walking
due to swelling. Patient also told that she feels fatigue when climbing 3-4 stairs and she suddenly
wake up from sleeping due to SOB. She needs to put 2 pillows to sleep because she feels suffocated.
(Paroxysmal nocturnal dyspnoea PND). Otherwise, no fever, chest pain, cough with frothy sputum,
headache, nausea, vomiting. He also denies any

RIGHT HF: (SOB, Leg swelling, fatigue and weakness)

CKD: no oliguria (l urine output), no nausea, vomiting, loss of appetite (fatigue, pruritus)

CLD: not having diabetes, not take alcohol, no abd pain, no weight gain, no bleeding tendency
(oedema, fatigue, jaundice, pruritus)

She went to ED at HRPZ to seek medical attention and the treatment was been given there and she
was in ICU for 5 days and was sent to medical wards on day 6 of admission (19/12).

Systemic review:

CNS: no dizziness. no headache, no confusion, no blurry vision

RESPI: no cough, no URTI sx

GIT: no UTI sx

MSK: no muscle pain

PMHX:

He has underlying pulmonary embolism, HPT, DVT, for 1 year. She was hospitalized before in June
2022 which is 1 year ago for pulmonary embolism at HUSM and also in January and march 2023 for
cellulitis at her left leg.

PSHX:

He has no know surgical history.

Drug HX:

She takes amlodipine 10mg OD for her HPT, warfarin OD for pulmonary embolism. And no known of
drug allergy

Family HX:
Both of her parents already died where her mother died at 61 y/o due to DM complication while her
father died at 60 y/o due to car accident. She has 6 siblings, and she is the third child. All of her
siblings are in good health.

Social HX:

She is unemployed. Her husband is self-employed, and he is 47 y/o. Her husband is a smoker and he
smoke one pack a day. She did not consume any alcohol or any drug abuse.

Diet HX:

She takes normal diet which is she eats 2 times per day, and she usually avoid taking any beans.

Summary:

my patient, 38 years old Malay women from Kota Bharu Kelantan complained of having leg swelling
with SOB 1 week prior to admission associated with fatigue, PND, orthopnoea. Otherwise, no fever,
no cough, no nausea, vomiting, and no weight gain.

Physical examination

My patient is conscious and alert, well oriented to time, place and person. She is lying comfortable in
45 degree position and cooperative. She is obese person, well hydrated and not cachexic. He is not in
respiratory distress. She is pale, cyanosed and jaundice.

The respiratory rate was 16 breath per minute, pulse rate was 80 beat per minute at regular rhythm
with good volume, normal character and no radio-radial delay, no collapsing pulse.

The hands is warm and dry to touch. There is no hand’s deformity, no muscle wasting, no obvious
rashes seen. At the nails, there is no clubbing finger, no leukonychia, no splinter’s haemorrhage, no
peripheral cyanosis and capillary refill time less than 2 second. Otherwise, there is no tar staining, no
tendon xanthomas, absent of Osler’s node and Janeway lesion.

B/P: 132/83

Head

Eyes: The conjunctiva is pale and there is yellowish sclera. No conjunctival pallor, corneal arcus and
xanthelasma.

Mouth: he has good oral hygiene, good hydration, no central cyanosis, glossitis or oral candidiasis.
Tonsil enlargement and palate deviation are also absent.

Leg: There is bilateral leg oedema. (from Ankle to below knee)

CHEST EXAMINATION

JVP :

Assessment of the JVP did not reveal any abnormalities and the hepatojugular test was negative No
bruit at carotid pulse.

Chest Inspection
Not reveal any scars or chest wall abnormalities. The apex beat was palpable in the 5th intercostal
space, in the midclavicular line, no parasternal heaves or thrills were noted.

Palpation.

The apex beat is at the 5th ICS, not displaced. The parasternal were not noted.

Auscultation:

Normal heart sound, no murmur

Mitral valve

Tricuspid valve

Pulmonary valve

Aortic valve

There is decreasing heart sound and the most prominent is on mitral and tricuspid valve.

s1 s2 is heard with no addition heart sound.

No systolic murmur (aortic stenosis) heard at carotid arteries

No murmur (aortic regurg - heard when pt hold their breath during expiration) heard at aortic area.

No pansystolic (mitral regurg)or mid diastolic (mitral stenosis - heard when patient roll to left )

Posterior chest wall Inspection

Scratch scar

Auscultation

The lungs are equal air entry and fine crepitation at both lower zones.

ABDOMINAL EXAMINATION

On inspection

The abdominal wall moves symmetrically upon respiration. The umbilicus is centrally located and
inverted. The abdomen is mildly distended. There is itching scar on the abdomen otherwise, no
stretch mark, no bruise.

On palpation

The abdomen is soft and non-tender. Liver span is 14 cm which is enlarged. Kidney is not ballotable,
and aorta is not palpable.

On percussion
There is no dullness when percussion is applied to the liver and spleen. No dullness during shifting
dullness assessment.

On auscultation: Bowel sound is normal. Aorta and renal bruits are absent.

Thank patient, cover back with clothes, Wash hands, Summarise findings! Lastly, I would like to
complete my examination with a suggestion of further assessments and investigations through
AUSCULTATION.

1. a record a 12-lead ECG – arrhythmias / myocardial ischaemia’

2. Dipstick urine – proteinuria / haematuria – hypertension

3. Bedside capillary blood glucose – diabetes

4. Perform fundoscopy – malignant hypertension – papilledema

5. external genitalia and rectal examination

Provisional Diagnosis:

Right sided heart failure secondary to pulmonary embolism

DDX:

1. RIGHT HF: (SOB, Leg swelling, fatigue and weakness)

2. CKD: no oliguria (l urine output), no nausea, vomiting, loss of appetite (fatigue, pruritus)

3. CLD: not having diabetes, not take alcohol, no abd pain, no weight gain, no bleeding tendency
(oedema, fatigue, jaundice, pruritus)

IX

FBC – TRO anemia, any infection

BNP brain natriuretic peptide – rule out HF if low, suspicion of HF, can be used as a baseline value for
monitoring purpose during treatment

Renal function- ruleout renal causes of volume overload, assess renal function

BUSE (blood urea serum electrolyte)- renal function

Liver function test- look for impaired hepatic function, TRO CLD,

ECG – To look for Q wave,

CXR : cardiomegaly, batwings appearance – pulmonary edema) TRO pneumonia

ECHO: ventricle size, thickness, diastolic fx of heart, valvular structure and fx, evidence of pulmonary
hypertension( ejection fraction, find any stenosis or regurgitation and visualize heart chambers)

Urinalysis – rule out renal causes or infection

CTPA – PE
MANAGEMENT

Pharmacological

Acute

ABC

Airway – ensure airway patent, if not intubate

Breathing – if spo2 ,95 give supplementary o1

Circulation – insert branula for medication administration and fluid resuscitation if needed

Diuretic therapy : therapy in pt fluid overload – frusemide

Vasodilators

Iv morphine

DVT rophylaxis in HF pt

-TED stocking

-direct oral anticoagulant

chronic

-Anticoagulant -low molecular weight heparin LMWH, unfractionated heparin, UFH.

Betablocker: metoprolol, bisoprolol - reduce heart rate and blood pressure, decreasing workload on
the heart.

ACE inhibitors: captopril, perindopril— improve blood flow and reduces strain on the heart

High intensity statin: atorvastatin- lower cholesterol levels, reducing the risk of future cardiovascular
events.

Mineralocorticoid receptor antagonist MRA: spironolactone

Non-pharmacological

Give education to patient to take medication routinely

Diet modification : Avoid high cholesterol diet

Weight control

Physical Exercise