Niranjana M Name: Mdm L Sex: Female Age: 68 Occupation: Housewife Date: 10/9/13

Presenting Complaint: Per-Rectal Bleed (PR Bleed) with chest pain on exertion History of Presenting Complaint: 68 Year old Mdm L presented with a history of 7-day PR bleed. It was described to be a painless watery discharge, not mixed with stools, and clot-free. There was dizziness after the bleeding episodes. Another symptom of right upper quadrant abdominal pain which onset a day ago. Upon admission two days ago, her regular medication, Warfarin, for the past 14 years was suspected for the PR bleed and stopped. However, the PR bleed continued. Significant events since admission include an episode of Bradycardia (40BPM) yesterday (9th Sept 2013) and was given I/V Atropine for relief. Mdm Ls chest pain has begun a few weeks ago, and it is a central crushing pain without radiation. It lasts for 2-3 minutes. It begins on exertion and its made better with rest. Past Medical History 30 Years old: Admission for fever and low blood pressure 58 Years old: Admission presenting with palpitations, shortness of breath. A cardiac catheterisation was done to diagnose the defect. Mitral valve insufficiency was identified along with atherosclerosis of coronary artery. Angioplasty with a balloon catheter was done at this instance. ECG test noted Atrial Fibrillation. 64 Years old: Another cardiac catheterization was done and the mitral insufficiency had worsened. Mdm L was asked to anticipate minor chest pain. Mdm L has Diabetes Mellitus, Hypertension and Hyperlipidemia. (The Triad for Metabolic syndrome, which is a significant risk factor for CHD) Drug History Metformin 50mg, b.d, Gliclazide 80mg, b.d, Omeprazole 40mg, o.d, Simvastatin 40mg, o.d, Digoxin 50micrograms, q.d.s, Raloxifen 60mg, o.d, Losartan Potassium-Hydrochlorothiazide (Hyzaar) 12.5mg, o.d, B12 and Folic acid Supplements One pill every day, Calcium and Vitamin D supplements One pill a day. No known allergies.

Niranjana M Family History Mdm L is married and lives with her son. Her husband has passed away. She has two more daughters in the USA. Her mother passed away when she was 80 years old due to Diabetes. Her father passed away when he was 90 years old due to a fall. Her youngest sister recently had Ductal Carcinoma. This may explain why she has been taking Raloxifen, a SERM. Social History Mdm L has not worked before and has been a housewife. She does not smoke however drinks a glass of wine over family events which, according to her, are less than 6 times in a year. She mentioned having a healthy diet and exercises by walking around her neighbourhood with her friends. Systems Review: CVS: Palpitations, SOB, Chest Pain RS: Occasional unproductive cough GI: Right Upper Quad Abdominal pain, PR bleed (with no alteration in stool habits), decrease in appetite NS: Dizzyness after PR bleeds, Lower limb paraesthesia GU: Menopause early at 42 years old. MS: None ES: Weight loss of 10kg over the past 2-3 weeks. DERM: Hematomas over limbs ICE Mdm L is aware that she has cardiac defects but does not exactly know what they are and how they affect her system. She allows her children to know the information on behalf of her and tell her the necessary. Although she knows her health is generally bad, she does not worry about anything as her children are all settled and well-to-do. She is aware she is growing old and is ready to face her health issues. She expects doctors to however at least let her know the basis behind certain procedures like cardiac catheterisation and bone marrow biopsy as they are invasive procedures that occur to her as more serious than non-invasive procedures like blood test analysis. Examination On general examination from the end of the bed, Mdm L looked pale and undernourished. She had an I/V cannula on her hand. Her vital signs are as follows: (At time of examination) Heart Rate 91bpm, Respiratory Rate 20, BP 165/70. Capillary refill time was about 3 seconds and fine tremor was present. Upon inspection of the eyes, she had a very pale conjunctiva indicative of anemia. The apex beat was slightly lateralized, about 1cm lateral to the mid-clavicular line at the 5th intercostal space. Thrills were felt at the apex. Upon

Niranjana M auscultation, 3 heart sounds could be heard with obvious pulsation upon placement of the stethoscope. Investigations A full blood count indicated Pancytopenia. ECG showed Atrial Fibrillation, Left Ventricular Hypertrophy, ST depression (mainly anterior and lateral and slightly in inferior) could indicate a Mitral Valve Prolapse with her history of mitral insufficiency, Inverted T waves (Inferior, lateral and anterior) could be because of ventricular hypertrophy or because she is under Digoxin. S waves up to V6 might indicate an axis deviation or bundle block. Bone marrow biopsy was done. (During the Biopsy, she had a Tachycardia episode with 127BPM) Summary A 68 year old, Chinese female under Warfarin presented with PR bleeding accompanied by chest pain, and has a history of Mitral insufficiency and CAD. Differential Diagnosis PR bleed (due to Warfarin) induced anaemia thats caused chest pain due to ischaemia. Bleed could persist because of residual effects of Warfarin (Only been two days since withdrawal) Bone marrow failure can cause thrombocytopenia: Myeloma, Myelofibrosis Viruses like HIV Hypersplenism, Splenomegaly Thiazide taken for hypertension (can cause thrombocytopenia bleed) Developing a stroke (lower limb paraesthesia) Management Plan Stop bleeding first, give Fresh frozen plasma, or Prothrombin complex, or Vitamin K. Schedule for echocardiogram and cardiac catheterisation. Consider Mitral valve replacement surgery. Tackle underlying pancytopenia cause. -blockers and Ca2+ channel blockers for Atrial Fibrillation. Date: 10th September 2013 Time: 12:45PM Signature: Niranjana