An old lady with breathlessness

A 70-year-old lady present to the clinic complained of breathlessness on exertion since a month ago. There was no chest pain but she felt palpitation occasionally. On further questioning, she mentioned that she had to sleep on 2 pillows at night and might wake up suddenly due to shortness of breath. She also felt tired easily and noticed some loss of weight. Her appetite was not good nowadays. She had no significant past medical history and family history. She did not smoke nor take alcohol.

On examination, the patient appeared tired ad there was no sign of cyanosis, pallor or jaundice. Her pulse rate was 110bpm, rhythm was irregularly irregular, volume was strong. Her respiratory rate was normal. Blood pressure was 150/70mmHg. JVP was raised. Body temperature was normal.

Examination of the heart showed that her apex beat was slightly displaced to the lateral. On auscultation, there was a ejection systolic murmur. Auscultation of the lung revealed basal crepitation. Abdominal examination showed slight enlargement of the liver, no splenomegaly, kidney not palpable. Peripheral pulses were all palpable, symmetry and strong. There was mild pedal oedema.

ECG showed irregular rhythm with normal QRS complex. There was no pattern suggestive of previous myocardial infarction. Chest X-ray showed signs of pulmonary oedema and cardiomegaly. Blood test was normal except for elevated serum T3, T4 level.

1. What is the most likely clinical diagnosis?

2. What type of irregular rhythm was expected on ECG?

Hypertension in a young lady

A young lady, 25, was diagnosed of hypertension after her third follow up in a clinic. Her history was normal. There were no suggestive history of renal diseases, pheochromocytoma, hyperaldosteronism, Cushing's syndrome and other endocrine disorders. Her family members did not have history of hypertension & diabetes mellitus. She denied taking medications such as OCP, steroids and others.

On examination, she appeared to be well and not obese. There were no signs of anaemia or Cushingoid features. Her blood pressure was 160/100 mmHg. Fundi examination was normal. There was no enlargement of thyroid gland. Abdominal examination did not reveal any organ enlargement.

However, on examination of her peripheral pulses. The clinician detected radio-femoral delay. On further auscultation, there was midsystolic murmur heard over the left interscapular space; together with bruit-like sound heard over lateral thoracic wall.The doctor ordered a chest X-ray immediately.

1. What is the clinical diagnosis?

2. What do you expect to see on the chest X-ray?

(Clue: clinical findings)

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A post-op elderly woman

A 70-year-old, obese woman, who was diagnosed of Cervical Ca, underwent a total hysterectomy with removal of both ovaries. The operation was successful.

On the day of discharge, she suddenly developed dyspnoea. The doctor found out that she was tachycardic, tachypneic and was in respiratory distress. There was no sign of deep vein thrombosis.

ECG was done immediately. ABG showed hypoxaemia.

1. What is the most likely diagnosis? What do you expect to see from ECG?

(Clue: Post-menopausal woman, obese, post-surgery, malignancy)

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