Heart Disease Program Diagnosis

Diagnosis Results for on case 4 at 13:49 Dec 9, 1998

Patient Name:

Patient: PT4 Note: DOB 10/10/1918 Description: angina and dyspnea

• History
  • age: 78 year old
  • sex: female
  • dyspnea: on-exertion for 1yr progressive
  • chest-pain: anginal chest-pain on-exertion for 1yr worsening
  • symptoms: syncope/near-syncope on-exertion for 10yr and fatigue for 1mo
  • known-diagnosis: of diabetes
  • therapies: on nothing
• Vital-Signs
  • blood-pressure: 150/70
  • heart-rate: 80
  • resp: 10
  • temp: 98.1
• Physical-Exam
  • appearance: appears in no-acute-distress
  • mental-status: conscious
  • chest: revealed basilar rales
  • jugular-pulse: normal
  • pulse: has slow-rise
  • auscultation: III/VI systolic-murmur at the lsb also at the neck
  • abdomen: normal
  • extremities: normal
• Laboratory-Findings
  • ekg: (1hr): sinus-rhythm and non-specific-st&t-changes
  • cxr: (1hr): cardiac-enlargement
  • blood-chemistry: (1hr): Na: 142 k: 4.5 bun: 15 creat: 0.8
  • cbc: (1hr): hct: 41 wbc: 5.4
• Additional-Laboratory-Findings
  • right-heart-cath: rt cath (1wk): w: 9 and ci: 2.9

BEST DIAGNOSTIC HYPOTHESIS

• AORTIC STENOSIS as indicated by pulse has slow rise, systolic murmur at the lsb, basilar rales, fatigue, ekg 1hr: non specific st&t changes, dyspnea on exertion, although ekg 1hr: no block, normal a2 s2, MITRAL STENOSIS PERM is false; causing
  • LV HYPERTROPHY as indicated by cxr 1hr: generalized enlargement, although ekg 1hr: no lvh
• CORONARY HEART DISEASE as indicated by anginal chest pain on exertion, anginal chest pain on exertion, anginal chest pain on exertion, ekg 1hr: non specific st&t changes
• Unaccounted findings: syncope/near syncope on exertion.

Explanation of items in other hypotheses:

• LV DIASTOLIC DYSFUNCTION as indicated by cxr 1hr: generalized enlargement, basilar rales, fatigue, dyspnea on exertion, although ekg 1hr: no lvh
• ISCHEMIC CARDIOMYOPATHY (possibly caused by CORONARY HEART DISEASE) as indicated by cxr 1hr: generalized enlargement, ekg 1hr: non specific st&t changes
• DILATED CARDIOMYOPATHY as indicated by cxr 1hr: generalized enlargement, ekg 1hr: non specific st&t changes

The findings (lower case) are explained by the hypotheses as follows:

• ISCHEMIC CARDIOMYOPATHY explained by CORONARY HEART DISEASE.
• anginal chest pain on exertion explained by AORTIC STENOSIS or CORONARY HEART DISEASE.
• cxr 1hr: generalized enlargement explained by DILATED CARDIOMYOPATHY, ISCHEMIC CARDIOMYOPATHY, LV DIASTOLIC DYSFUNCTION or LV HYPERTROPHY.
• ekg 1hr: non specific st&t changes explained by DILATED CARDIOMYOPATHY, ISCHEMIC CARDIOMYOPATHY, CORONARY HEART DISEASE or AORTIC STENOSIS.
• basilar rales, fatigue and dyspnea on exertion explained by LV DIASTOLIC DYSFUNCTION or AORTIC STENOSIS.
• pulse has slow rise and systolic murmur at the lsb explained by AORTIC STENOSIS.
• syncope/near syncope on exertion is unaccounted.