GENERAL MEDICINE CASE

CASE DISCUSSION OF A PATIENT WITH SHORTNESS OF BREATH  AND PEDAL EDEMA 

     By surigi Mounika Roll .no.160

I have been given this case to solve in an attempt to understand the topic of "patient clinical and analysis "to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, diagnosis and come up with a treatment plan. 

You can find the entire real patient clinical problem in this link https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

Following the analysis of the patient, priority order of patient complaints as follows:

1.shortness of breath 

2.pedal edema

3.fever with chills 

But chronological order of patient complaints is:

1.fever with chills 

2.shortness of breath 

3.pedal edema

       FEVER WITH CHILLS

• 1 Month ago
• High grade 
• Associated with chills 

     Probable causes are:

• Infections : viral , bacterial,parasitic. 
• Malignancies 
• Autoimmune conditions like RHEUMATOID ARTHRITIS or SLE 
• Meningitis 

     . Other: drugs 

EVACUATION of the cause:

1.no history of rash and       abdominal pain( typhoid)no history of sharp chest pain and clammy skin(pneumococcal pneumonia), no history of cough and evening rise of temperature ( TB).so, bacteria originate is ruled out. 

2.viral infection may be due to high grade fever. 

3.malaria

4.no history of weight loss, loss of appetite ( chacexia) so, malignancies are ruled out. 

5.no history of joint pain .thus RA is excluded 

6.no history of headache, Vomiting and altered consciousness. Thus meningitis is excluded. 

TREATMENT:

   Was treated symptomatically by antimalarials by local rmp.

       SHORTNESS OF BREATH 

• since 2 weeks 
• Initially it was NYHA 3 

Now it was NYHA 2 after  treatment. 

Differential to shortness of breath

•  Pulmonary: obstructive or interstitial, vascular, restrictive.
• Cardiac : valvular , arrhythmias.
• Renal
• Gastrointestinal
• Neuromuscular 
• Anemia 
• Psychological

EVACUATION of cause for SOB:

1.no history of cough, wheeze.thus respiratory system is excluded. ON EXAMINATION THERE IS EARLY INSPIRATORY CREPTS( appreciated incongestive heart failure).THIS EXCLUDES respiratory system. As PAN INSPIRATORY or LATE INSPIRATORY CRACKLES are seen in interstitial type of pulmonary fibrosis 

2.no history of oliguria and periorbital edema. Thus renal system is excluded. 

3.no history of tingling ,numbness muscle pain. Thus neuromuscular system is excluded. 

4.There is no history of GIT reflux disease.

5.there is no evidence if low Hb%, but patient was fatigue and PND

6.no significant drug history. 

BASED ON ABOVE EVALUATION I THINK ORIGIN OF SOB WAS DUE TO 

1.CARDIAC SYSTEM INVOLMENT

2.ANEMIA 

      

         PEDAL EDEMA 

  
• Which was bilateral 
• Since two weeks 
• Progressive in nature extended upto knees 

  
 Differentials for PEDAL EDEMA:

• Cardiac disease 
• Liver disease 
• Kidney disease 
• Thyroid disease 
• Malnutrition 
• Lymphedema 
• Medications: NSAIDS,CALCIUM CHANNEL BLOCKERS CORTICOSTEROIDS, ETC. 

Evaluation if cause of bilateral PEDAL EDEMA:

1.there is no history of oliguria and facial edema.thus renal cause is excluded. 

2.there is no significant drug history. 

3.malnutrition is ruled as there is no abdominal distention. 

4.ascites is present but not significant. Thus liver cause is excluded. 

 

BY THIS TIME I THINK IT IS THE CARDIAC CAUSE FOR HIS PEDAL EDEMA. 

 

PATHOLOGY IN HEART WHICH CAUSES 

1.SOB

2.BILATERAL PEDAL EDEMA 

3.FATIGUE 

4.ASCITES 

Left ventricular failure symptoms: SOB and fatigue. 

Right ventricular failure symptoms:Bilateral Pedal edema and ascites.

SO , patient has congestive heart failure which is systolic type : 

2D echo: evidence of systolic type of heart failure by decreased EJECTION FRACTION-27%

Normal EF-50 - 70%

                       |

As there is no chest pain , palpitations, syncope attacks ( so MI,  MS and AS are excluded. 

                        | 

  So, my DIAGNOSIS is DILATED CARDIAC MYOPATHY WITH VIRAL MYOCARDITIS .

INVESTIGATIONS USEFUL IN THIS CASE ARE: 

ECG 

MRI

2D ECHO

• EF-27%
• IVC dilated(2.3cm)not collapsing
• end point septal separation distance is increased
• mild TR+,severe MR+,trivial AR+
• dilated all chambers
• global hypokinesia
• severe LV dysfunction
• mild PAHT
• no MS/AS,no PE/LV clot

PCR

USG ABDOMEN

CBP

LFT

RFT

TREATMENT:Pharmacological

1.DIURETIC :Tab.lasix 80mg...40mg...40mg to treat edema.

2. For heart failure and hypertension:a> tab.isosorbide mononitrate10mgbd.

b>tab hydrazine 25mg

c>Telmisartan 20mg.

 

NON PHATMACOLOGICAL:

1.Fluid restriction <1 litre / day

2.salt restriction < 2gms / day.

 

RECENT TREATMENT: 

VYMARDA 50 MG BD INCRESED TO100MG BD.

TREATMENT SUGGESTED:

1.ACE INHIBITORS  .

2ARBS

3.BETA BLOCKERS. 

REFERENCE:

1.https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

2.https://hitesh116.blogspot.com/2020/05/elog-14th-may-2020.html?m=1

3.http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/medclerk/2004_05/level1/Lungs/lungs_f.htm

4.Davidsons principles of medicine.