09-08-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED ATER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
Disclaimer:
This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.
Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
Date of data collection: 9th august 2025
Demographic data:
Age: 31 years
Gender: Male
Occupation: Hawker
Address: Cooch Behar, West Bengal, India
Chief complaints:
Chest pain since 5 years
Shortness of breath on exertion since 5 years
History of Presenting Illness:
The patient was apparently asymptomatic 5 years ago when he gradually developed chest pain on exertion. The chest pain progressively increased in intensity and duration, resulting in a decrease in exercise tolerance. The pain is crushing type, non-radiating, aggravated on less than ordinary physical activity and relieved on rest. Patient also complained about pain below knees.
From previous consultation notes taken 2 months ago, the patient consulted a doctor for chest pain, where a 2d echo was done, and he was told that he has a bicuspid aortic valve, which is leading to aortic stenosis, and he requires surgery. The patient refused surgery and took medications (unknown), which provided him some relief, but he discontinued these as they were expensive
The patient also complains of dyspnoea on exertion since 5 years, NYHA grade III, aggravated by less than ordinary physical activity. relieved on taking rest
Chest pain: as described by the patient and translated by patient’s advocate, “its like putting a huge rock on chest”
Aggravating factors of chest pain and SOB: on slight exertion of daily activities like climbing stairs, walking for long distances (approx >100m), lifting heavy objects.
Relieving factors of chest pain and SOB: taking rest, lying down.
No history of Rheumatic fever. Supported by serum ASO test done on 26 May 2025.
No history of HTN, DM, Epilepsy, TB, Thyroid disorders.
No prior significant medical history.
Currently not taking any medication.
Medical History:
No comorbidities.
Family History:
No significant family history
Personal History:
No known allergies.
Addiction history: no history of smoking. History of oral tobacco consumption since 8 years. Occasionally consumes alcohol
Diet: mixed
Appetite: decreased
Bowel and bladder: regular and normal
10-12 years old: fell in river while playing football. Didn’t learn swimming. He was saved by someone. He was scared.
Weight: approx. 52 kgs
General Examination:
No history of pedal edema, cyanosis, syncope, Palpitation, GI distress
No history of polyarthralgia, chorea, or subcutaneous nodules.
History of SOB at night- PDN, Orthopnea
Investigations and Findings:
03 September 2025:
ECG:
HR: 79/min
Impression: Left Ventricular Hypertrophy by voltage
Echo Cardiography Color doppler:
Mitral valve: flutter present
Aortic root: AV structure - thick, root diameter - 32.8 mm, cusp opening - 18.4mm
Pulmonic Valve: Evidence of PULMONARY ARTERIAL HYPERTENSION.
Tricuspid Valve: normal
LEFT ATRIUM: LA Dimension: 35.7 mm
LEFT VENTRICLE: LV Int. Diameter (Syst): 27.9 mm, LV Int. Diameter (Diast): 57.3 mm, IVS Thickness (Diast): 10.6 mm, LVPW Thickness (Diast): 10.0 mm
LEFT VENTRICULAR FUNCTION: Ejection Fraction: 82 %, Fractional Shortening: 51 %
RIGHT VENTRICLE: RV Int. Diameter (Diast): 13.2 mm
Xray Chest: Normal Study
Images:
25 May 2025
Serum ASO titre: <200 IU/ml of serum
Random Plasma glucose: 109mg/dl
Hb: 12.4 g/dl
WBC total count: 7300/cu. Mm
Images:
25 June 2025
Echocardiography:
Mitral valve: Morphology: Normal, Regurgitation: Absent
Aortic Valve: Morphology- Bicuspid, regurgitation- moderate
Tricuspid: Morphology: Normal, Regurgitation: Trivial
Pulmonary: Morphology: Normal, Regurgitation: Absent
Bicuspid aortic valve, Severe AS, Moderate AR, Normal biventricular function, Mild PAH
Images:
9 August 2025
https://www.youtube.com/watch?v=WzzaMKz4VdY
Diagnosis:
Bicuspid Aortic valve causing Aortic Stenosis with Angina pectoris and exertional dyspnea.
Recommended Approach (by Perplexity.ai)
For a 30-year-old male patient, the recommended management strategy should include:
Immediate: Comprehensive exercise testing to assess functional capacity and symptoms
Surgical consultation: Evaluation at a specialized valve center with expertise in all options
Primary recommendation: Ross procedure if anatomically suitable and performed at an expert center
Alternative: Mechanical valve replacement if Ross procedure not feasible
Close monitoring: Serial imaging every 6 months given the severe stenosis and moderate regurgitation
The excellent long-term prognosis can be achieved with appropriate surgical intervention, with the Ross procedure offering the best outcomes for restoration of normal life expectancy in young adults with bicuspid valve disease.
[09-08-2025 10.40] PPM 1: 2D Echocardiography findings yesterday
[09-08-2025 12:19] PPM 1: Some questions we had around this patient's potential solutions after a Web 0.0 discussion with @~K Naveen in the OPD now 👇
[09/08, 12:14]cm: Is the artificial aortic valve well designed for coronary filling?
[09/08, 12:15] Meta AI: The design of artificial aortic valves, particularly those used in transcatheter aortic valve replacement (TAVR), has evolved to improve coronary filling and access. Here's how:
Key Design Considerations
- Commissural Alignment: Aligning the prosthetic valve's commissures with the native valve's commissures can facilitate coronary access and improve valve hemodynamics. Studies have shown that commissural alignment reduces coronary overlap and improves coronary filling.
- Implantation Depth: Optimal implantation depth is crucial to prevent coronary obstruction and ensure proper valve function. A higher implantation depth may complicate coronary access, while a lower depth can increase the risk of conduction disturbances.
- Valve Design: Self-expanding valves, like the Evolut FX, are designed to improve deliverability, trackability, and deployment accuracy. These valves have features like radiopaque markers to guide implantation and optimize coronary access.
Benefits of Improved Design
- Better Coronary Access: Commissural alignment and optimal implantation depth can facilitate selective cannulation of coronary arteries after TAVR.
- Reduced Complications: Improved valve design and implantation techniques can reduce the risk of coronary obstruction, conduction disturbances, and permanent pacemaker implantation.
- Enhanced Valve Hemodynamics: Commissural alignment has been associated with improved valve hemodynamics, including reduced transvalvular gradients and aortic regurgitation.¹
Ongoing Developments
- New Valve Designs: Next-generation valves, like the Evolut FX, are designed to improve coronary access and reduce complications.
- Advanced Imaging Techniques: CT scans and fluoroscopy are used to guide implantation and optimize coronary access.
- Refined Implantation Techniques: Techniques like the cusp overlap projection and double S-curve model can improve implantation depth and coronary access.²
[09-08-2025 12:21] PPM 1: @PPM5 you know a similar patient of aortic stenosis who was much luckier than this patient in getting a valve replacement done. It would be interesting to compare both the illness trajectories here. Would you also like to talk to this patient once @PPM6 and @PPM7 share the initial history of the patient?
[09-08-2025 13.23] PA:
[09-08-2025 16.18] PPM 1: Aei pain killer tai kidney khoti hote pare. Eta na khawai bhalo.
@PPM3 what is his current serum creatinine tested here?
[09-08-2025 16.19] PPM 1: Afternoon session:
Reviewed his 2D echocardiography particularly for the aortic valve pressure gradient and valve cusps and the severity of AR
[09-08-2025 16.22] PPM 1: @PPM8 check out the three aortic valve cusps in this image
[09-08-2025 17:19] PPM 1: [09/08, 16:33] Dhu AS 1: Sir.. previous reports say he was diagnosed with bicuspid valve..
[09/08, 17:04] cm: Yes that's what we are contesting with our current findings.
However the diagnosis can only be confirmed when we remove the valves operatively or even just examine them during OT
[09/08, 17:07] Dhu AS 1: aren't there any non invasive tests to confirm it before intervention sir?
[09/08, 17:12] cm: Echocardiography
[09/08, 17:13]cm: Trans esophageal echocardiography if it's still not clear on transthoracic (the one which we did was transthoracic)
[09/08, 17:14]cm: Would the TAVR management plan change between vicious and tricuspid aortic valve?
[09/08, 17:14] Meta AI: Yes, the TAVR (Transcatheter Aortic Valve Replacement) management plan may differ between a bicuspid and tricuspid aortic valve due to anatomical and functional differences between the two valve types. Here's how:
Bicuspid Aortic Valve (BAV)
- Anatomical Considerations: BAVs often have larger annuli, more elliptical shapes, and asymmetric leaflet calcification, which can affect valve sizing and positioning.
- TAVR Feasibility: TAVR is feasible in BAV patients, but may require more precise valve sizing and positioning due to the valve's unique anatomy.
- Potential Challenges: BAV patients may experience higher rates of paravalvular leak, valve embolization, or coronary obstruction due to the valve's anatomy.
Tricuspid Aortic Valve (TAV)
- Anatomical Considerations: TAVs typically have more symmetrical leaflets and a more circular annulus, making valve sizing and positioning relatively more straightforward.
- TAVR Feasibility: TAVR is well-established for TAV patients, with more predictable outcomes due to the valve's anatomy.
Key Differences in TAVR Management
- Valve Sizing: More precise valve sizing may be required for BAV patients due to their unique anatomy.
- Valve Positioning: BAV patients may require more careful valve positioning to ensure proper seating and minimize complications.
- Imaging Guidance: More detailed imaging guidance, such as CT scans, may be necessary for BAV patients to ensure accurate valve sizing and positioning.
Implications
Understanding the differences in TAVR management between bicuspid and tricuspid aortic valves is crucial for optimizing patient outcomes. BAV patients may require more tailored approaches to valve sizing, positioning, and imaging guidance to address their unique anatomical challenges.
[09-08-2025 20:55] PPM 1: Abbreviations:
Dhu-dyadic human user
cm-cbble moderator
[09-08-2025 21.12] PPM 1: The telephone PaJR team has compiled a fine document for this patient here: https://docs.google.com/document/d/1fCTz10IWFPYqHv37777F5tASBF1w4YhUUypRJKdQ5U4/edit?usp=sharingSharing more dyadic conversations to prepare the discussion @PPM3 @PPM4
[09/08, 17:37] Dhu AS 1: ## Analysis of 2D Echo Image - Parasternal Short Axis View of Aortic Valve
Based on the echocardiographic image provided, this appears to be a *parasternal short axis (PSAX) view at the aortic valve level* obtained during systole.
### Key Findings:
#### 1. *Aortic Valve Morphology*
- The image shows what appears to be an *aortic valve in the open position* during systole[^1][^2][^3]
- The valve opening pattern is consistent with a *"fish-mouth" or oval appearance* rather than the normal triangular opening of a tricuspid valve[^4][^5][^6]
- This morphology is *characteristic of a bicuspid aortic valve*[^5][^6][^4]
#### 2. *Bicuspid Aortic Valve Configuration*
- The valve appears to have *two functional cusps* rather than the normal three leaflets[^6][^7][^1]
- The opening pattern shows the typical *asymmetric, elongated orifice* seen in bicuspid valves during systole[^4][^5][^6]
- This is consistent with your previously mentioned diagnosis of bicuspid aortic valve with severe stenosis
#### 3. *Valve Function Assessment*
- The valve appears to be *opening, though the degree of opening appears **restricted*, which would be consistent with severe aortic stenosis[^2][^7]
- The *thickened and possibly calcified leaflets* are visible, which is typical for stenotic bicuspid valves in young adults[^8][^7][^5]
#### 4. *Image Quality and Technical Aspects*
- This is a *well-centered PSAX view* at the aortic valve level[^3][^9][^2]
- The *aortic root appears circular*, indicating proper alignment without off-axis angulation[^9][^3]
- The surrounding structures including the *right ventricular outflow tract* are visible[^2][^9]
### Clinical Correlation:
This echocardiographic appearance is *entirely consistent* with your clinical presentation of:
- *Bicuspid aortic valve* with severe aortic stenosis[^7][^6]
- The *restricted valve opening* supports the severe stenosis diagnosis[^7]
- The *valve morphology* confirms the bicuspid nature rather than tricuspid[^5][^6][^4]
### Additional Recommendations:
1. *Doppler assessment* would be needed to quantify the severity of stenosis and regurgitation[^7]
2. *Multiple acoustic windows* should be used for comprehensive evaluation[^7]
3. *Assessment of the ascending aorta* is important given the bicuspid valve diagnosis[^7]
This image provides excellent visualization of the bicuspid aortic valve morphology and supports the clinical diagnosis of severe aortic stenosis that was previously discussed regarding your treatment options.[^6][^4][^7]
[09/08, 20:02]cm: Amazing 👏👏
Although again it would be perhaps better to give it a video data rather than go by it's ability to extrapolate based on a single image
[09/08, 20:08] Dhu AS 1: i tried with the video sir.. it asked to upload an image as it couldn't read and interpret the video
[09/08, 20:10] Dhu AS 1: I think we have to confirm it with an experienced human too before coming to a conclusion as it seems like something that can jeopardize the procedure if we are not 100% sure whether its BAV or TAV sir
[09/08, 20:14]cm: Yes don't worry. The person doing a TAVR would definitely confirm that as a first step
[09/08, 20:15] Dhu AS 1: okayy sir
[09/08, 20:19]cm: Now what is actually where we need to focus and try to move and shake is the fact that this man cannot get it done due to lack of money!
Inspite of the fact that TAVR technology is hyped and made inaccessible for poor patients just because a Western research group innovated it first and is supposed to be gaining that money although it's likely that a middle man, business man is gaining that money and this 31M will never get to have this procedure.
Our government hospitals are unable to get these technology because of market forces that force our politicians to not look after their poor!
[09/08, 20:25] Dhu AS 1: seems like average cost of procedure is 5 lakh INR in hyderabad sir
is this procedure done at Osmania or Nims..?
may be we can start a fundraiser or apply for CMRF
[09/08, 20:30]cm: CM here can't cater to this patient as he is from West Bengal.
5 lakhs is too much to raise and then it's not just one patient!
[09/08, 20:31] cm: The only place that has catered to such patients in the past and still does although he may have to wait in que for three years is Puttaparthi or even Whitefield Sai hospital
[09/08, 20:35] Dhu AS 1: I think he should enroll there and try if he can find another way while he waits sir
[09/08, 20:36] Dhu AS 1: may be he can also try to apply for CMRF in WB?
[09/08, 20:55] Dhu AS 1: can we consider SAVR in this patient sir?
[09/08, 20:55] Dhu AS 1: # Free Surgical Aortic Valve Replacement (SAVR) in India
Although Transcatheter AVR (TAVR) is usually paid, *surgical AVR (SAVR)—the gold-standard therapy—is routinely offered **free of charge* at major government and teaching hospitals under national and state health schemes. Eligible patients can receive SAVR without out-of-pocket expense through:
| Hospital / Scheme | Coverage Details |
|-------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------|
| NIMS Hyderabad (“Heart to Heart” charity program) | Provides fully *free open-heart surgeries*, including SAVR, for patients below the poverty line; >263 cardiac operations performed free[1]. |
| Osmania General Hospital (Afzal Gunj) | Offers *free cardiac surgeries*—valve replacements included—under state funding and CM relief funds; >450 procedures/month free for indigent patients[2]. |
| Gandhi Hospital (Secunderabad) | Delivers *no-cost open-heart procedures*, including SAVR, to BPL and Arogyasri-eligible patients in its govt cath-lab and ICU facilities[3]. |
| Rajiv Gandhi Government General Hospital (Chennai) | As a CM-scheme empaneled center, provides *free SAVR* under the Chief Minister’s Comprehensive Health Insurance Scheme; thousands of valve surgeries annually[4]. |
| *Ayushman Bharat (PM-JAY)* | Covers SAVR cost (up to ₹5 lakh) at empaneled public hospitals nationwide for ≤40 million low-income families[5]. |
| *Aarogyasri (Telangana)* | Fully funds SAVR at empaneled govt hospitals (Osmania, Gandhi, NIMS), including pre- and post-operative care, for BPL households. |
*Key Point:*
Patients with bicuspid or degenerative aortic stenosis who qualify under *PM-JAY, **Aarogyasri, or state Chief Minister schemes should approach the cardiology/cardiac surgery departments of government teaching hospitals to access **free SAVR*, which remains the definitive, long-term corrective treatment.
[09/08, 21:02]cm: Yes we could try this but not sure of the follow up data of all these SAVRs that have been done in the past. Short of that, can't be sure if they really improved their quality of life or worsened it!
[09/08, 21:07] Dhu AS 1: True.. guess we have to being changes at policy levels to include such surgeries under government schemes
[10-08-2025 21:31] PPM 3: His sr. creat is 1.0 sir
[11-08-2025 09:33] PPM 1: @PPM7 any further leads to where we can send him in Hyderabad for a free aortic valve replacement?
[11-08-2025 09:46] PPM 6: For TAVR there are no centers offering the surgery currently sir.. there is also no government scheme to fund the surgery.
for SAVR, NIMS and Osmania are offering under Ayushman Bharat / aarogyasri sir. if we are considering SAVR then I will confirm if they are offering for free with the hospital sir.
[11-08-2025 09:49] PPM 1: Will need to check with patient advocate if they have ayushman bharat as arogyashree is specifically only for Telangana patients I guess
[11-08-2025 10:09] PA: Amader kache ayusman bharat card nai sir
[11-08-2025 10:36] PPM 1: @PPM3 @PPM10@PPM11 let's discharge both this and the gastric outlet obstruction patient today as per their wishes above and they will continue to follow up with us.
This patient will get his upper GI endoscopy from Hyderabad somewhere (their favourite is perhaps AIG, albeit costly)
[11-08-2025 10:53] PPM 3: Ok sir
[11-08-2025 11:46] PPM 6: @PPM1Sir
Based on my research of the Telangana CMRF website and related sources, here are the findings:
## *CMRF Coverage for TAVR*
*Yes, TAVR is covered under Telangana CMRF. The official CMRF guidelines state that the fund covers "health problems which require expensive medicare*". TAVR qualifies as:[1]
- A critical, life-saving cardiac procedure
- An expensive medical treatment (typically costing ₹2.5-5 lakhs)
- A procedure for patients in medical distress requiring immediate financial assistance
The fund does not maintain an exhaustive list of specific procedures but covers expensive medical treatments that patients cannot afford, which includes advanced cardiac interventions like TAVR.[2][3][1]
## *Hospitals in Telangana Offering TAVR*
Based on my research, the following hospitals in Hyderabad/Telangana offer TAVR procedures:
### *Major TAVR Centers:*
1. *Yashoda Hospitals* - Hitec City, Hyderabad
- Dr. V. Rajasekhar (Certified TAVR Operator)[4][5]
- Experienced in over 150+ TAVR procedures
2. *Apollo Hospitals* - Jubilee Hills, Hyderabad
- First Transcatheter Heart Valve clinic in the city[6]
- Only hospital with hybrid cath lab
- More than 150 TAVIs performed (highest in AP/Telangana)[6]
3. *KIMS Hospitals* - Secunderabad
- Dedicated TAVR/TAVI Centre[7]
- Team of TAVI specialists
4. *PACE Hospitals* - Hyderabad
- Leading center for TAVI/TAVR procedures[8]
- World-class Cath Lab facilities
5. *Citizens Specialty Hospital* - Hyderabad
- Frontrunner in TAVR surgery[9]
- Minimally invasive cardiac procedures
6. *Sri Sri Holistic Hospitals* - Hyderabad
- TAVR procedures for high-risk patients[10]
- Experienced TAVR doctors
7. *ONUS Heart Institute* - Hyderabad
- Comprehensive TAVI program [11]
- Focus on high-risk patients
8. *TX Hospitals* - Hyderabad
- Advanced valve therapies [12]
- Hybrid operation theatres
## *CMRF Application Process*
- *Online only* via cmrf.telangana.gov.in (since July 2024)[13][14]
- *24-hour processing* for Letter of Credit (LOC)[3][2]
- *No residency requirement* - covers treatment in Telangana regardless of patient's home state [15][16]
*Summary:* TAVR is definitely covered under Telangana CMRF, and multiple premier hospitals in Hyderabad offer this procedure. You can apply for financial assistance through the online portal, providing documentation of your treatment plan and financial need.
[11-08-2025 11:47] PPM 6: even non-residents of Telangana can apply for cmrf if they have income proof suggesting they are below poverty line (BPL). documents like food security card or ration card.
[11-08-2025 11:56] PPM 1: Would it become completely free of cost for them or are their hidden costs?
Would you and @PPM4 @PPM3 try to talk with them regarding their current objectives around availing this to understand if they don't want to avail it then why don't they want to avail it?
[11-08-2025 12:17] PPM 6: they might have to bear initial appointment cost sir.. and testing costs if necessary. if possible can you try and confirm if KIMS Secunderabad actually offers TAVR under cmrf sir.
[11-08-2025 12:17] PPM 6: we will talk to them sir
[11-08-2025 12:41] PPM 6: @PPM1Sir
we talked to the patient advocate sir.. patient has a ration card (would be sufficient proof of income to avail CMRF). but the document is at their home.
They don't want to have the procedure as they have financial problem and having surgery and taking off from work after surgery would add to the problem.
I asked them to take time and decide as its a critical condition.
[11-08-2025 12:42] PPM 6: Thanks to @24FPA for helping with translation on call
[11-08-2025 12:45] 24FPA: 🙏🏻😇
[11-08-2025 12:52] PPM 1: I talked to the advocate in OPD. It appears they are scared of surgery!
[11-08-2025 12:52] 24FPA: I also thought so
[11-08-2025 12:59] PPM 6: yes sir
[11-08-2025 13:10] PPM 1: What is the natural history of aortic stenosis once the patient develops angina @Meta AI?
[11-08-2025 13:10] Meta AI: Aortic stenosis is a progressive condition where the aortic valve narrows, impeding blood flow from the heart to the rest of the body. Once symptoms develop, the prognosis worsens significantly unless the obstruction is relieved through aortic valve replacement.
Key Outcomes After Developing Angina:
- Average survival rate: 5 years after the onset of angina, 3 years after syncope, and 1-2 years after congestive heart failure symptoms appear
- Mortality rates: Medical treatment for newly diagnosed moderate to severe symptomatic aortic stenosis is associated with a 25% mortality rate at one year and 50% at two years
- Sudden cardiac death: Accounts for half of the deaths in patients with severe symptomatic aortic stenosis¹ ²
Impact of Valve Replacement:
- Aortic valve replacement (AVR) significantly improves survival rates and quality of life for patients with severe symptomatic aortic stenosis
- Transcatheter aortic valve replacement (TAVR) is a viable option for high-risk patients, showing improved survival rates compared to medical therapy alone³
Factors Influencing Disease Progression:
- Aortic jet velocity: Higher velocities are associated with a greater likelihood of symptom onset and adverse outcomes
- Age and comorbidities: Older patients with coexisting conditions like coronary artery disease, hypertension, and renal insufficiency are at higher risk for rapid disease progression⁴
Early intervention with AVR is crucial for improving outcomes in patients with severe symptomatic aortic stenosis. Regular monitoring and timely treatment can significantly impact patient survival and quality of life.
[11-08-2025 13:10] Meta AI: https://radiologykey.com/transcatheter-aortic-valve-replacement-tavr-a-clinicians-perspective-aortic-stenosis-natural-and-unnatural-treated-history/
[11-08-2025 13:10] Meta AI: https://www.openaccessjournals.com/articles/what-do-we-know-about-the-natural-history-of-severe-symptomatic-aortic-valve-stenosis.html
[11-08-2025 13:10] Meta AI: https://cardioblogger.com/natural-history-of-aortic-stenosis-summary/
[11-08-2025 13:10] Meta AI: https://www.wikidoc.org/index.php/Aortic_stenosis_natural_history,_complications_and_prognosis
[12-08-2025 09.19] PPM 1: EMR SUMMARY:
Name:
UHID:
PID:
Age/Gender: 32 Years / Male
Pay Type: Paying
Address: —
Discharge Type: Relieved
Admission Date: 07/08/2025, 09:52 PM
Discharge Date: 11/08/2025
Name of Treating Faculty:
Diagnosis
Internal Medicine:
Severe Aortic Stenosis with moderate pulmonary Hypertension
Calcification left coronary cusp
Suspicion of bicuspid aortic valve
Chronic angina NYHA II
No CCF
Normal sinus rhythm
External Medicine (social diagnosis):
Social phobia of aortic valve surgery
Socio economic challenges to obtaining surgery or lesser invasive TAVR @PPM12 @PPM13 @PPM6 @PPM9 @PPM14 for the book chapter
Case History and Clinical Findings
Patient came with C/O shortness of breath (SOB) and palpitations while working since 3 months.
C/O weakness after doing work for some time.
History of Present Illness (HOPI):
Patient was apparently normal 3 months back. Then he developed SOB while doing work, which he did not have before.
Insidious onset, progressive from weakness to SOB and palpitations, aggravated on physical activity.
H/O palpitations intermittently since 3 months.
No H/O orthopnea, PND, chest pain, pedal edema.
No H/O fever, burning micturition, diarrhoea, constipation, headache, blurring of vision, neck stiffness.
H/O chest pain in 2021 — consulted cardiologist and was on medication for 2 months, then stopped medication and used homeopathic medication for next 1 year.
No history of: DM, HTN, asthma, TB, CVA, CAD, epilepsy, thyroid disease.
---
Personal History
Appetite normal, mixed diet, regular bowel and bladder movements.
No known allergies.
Addictions: Chewing tobacco since 10 years.
Family history: Not significant.
---
General Examination
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
Vitals:
Temperature: 98.7°F
BP: 90/70 mmHg
RR: 22 cpm
PR: 78 bpm
SpO₂: 98% (at room air)
---
Systemic Examination
CVS: S1, S2 heard; pan-systolic murmur at aortic, pulmonary, tricuspid areas; ejection click in mitral area heard.
RS: B/L NVBS heard.
Per abdomen: Soft, non-tender.
CNS:
Tone: Right & Left normal
UL: N, N; LL: N, N
Power: UL 5/5 (Right & Left), LL 5/5 (Right & Left)
Reflexes:
B: +2, +2
T: +2, +2
K: +2, +2
A: +2, +2
P: F, F
---
Investigations
Serum Creatinine (09-08-2025, 08:41 PM): 1.0 mg/dl (3-0.9 mg/dl mentioned)
Hemogram (09-08-2025, 05:34 PM):
Hemoglobin: 12.1 g/dl
Total WBC count: 9900 cells/mm³
RBC count: 4.0 millions/mm³
PCV: 34.8 vol%
MCV: 88.1 fl
MCH: 30.6 pg/dl
MCHC: 34.8 g/dl
RDW-CV: 13.10%
RDW-SD: 42.90 fl
Platelet count: 1.8 × 10³/mm³
Neutrophils: 45%
Lymphocytes: 43%
Eosinophils: 5%
Monocytes: 7%
Basophils: 0%
---
Follow Up
Review after 2 weeks.
---
When to Obtain Urgent Care
In case of any emergency, immediately contact your consultant doctor or attend the emergency department.
---
Preventive Care
Avoid self-medication without doctor’s advice.
Do not miss medications.
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