Spth Case Study In Nursing

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Case Write Up Mitral Stenosis with Secondary Pulmonary HTN Student name: Olla Alkhoja Student ID: u00036115 Demographics: Name: S. M. MRN#: 00089993 Age: 34 years Sex: Female Nationality: Indonesia Marital status: Married Occupation: house maid Chief Complaint: 34 y.o. female presenting with coughing of blood for the past week. Hx of Presenting illness: S. M. presented to the OPD with a 7 day history of cough. The cough is dryand occasionally contains streaks of blood.The coughing has increased in frequency throughout the past week. The cough is related to lying on her back. It is exacerbated by working for long hours and is relieved by resting on a pile of 3 pillows. The cough has not awakened her from her sleep. The cough is…show more content…
Vital signs: BP 107/74 mmHg Pulse 74 bpm RR 18 br/min Temp. (oral): 36.4 DegC SpO2: 100% Hands: Normal capillary refill. No peripheral cyanosis, no tar stains, no nail changes (koilonychia/onycholysis), no splinter hemorrhages, no tendon xanthomas, no osler’s nodes, no janeway’s. Pulse: 80 bmp irregularly irregular and of good volume. No radio-radial or radio-femoral delay. Head and Neck: No scleral icterus, no pallor conjunctiva, no corneal arcus, no xanthelasma. Pupils reactive to light. No loss of outer one third of eyebrows. No mitral facies, no angular stomatitis, no glossitis, no central cyanosis. Good dental hygiene. Normal arch palate. JVP not raised. Carotid pulses are normal (no bruits). Thyroid non-enlarged. Chest: -Heart No pacemaker, no scars or bruises, no abnormal pulsations. Apex beat is in the 5th intercostal space, midclavicular line. No thrills or parasternal heave. Normal heart sounds (S1 and S2) but irregular with added diastolic rumbling murmur and opening snap. -Lungs No labored breathing. Normal chest expansion, normal tactile

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