GENERAL MEDICINE CLINICAL CASES


CASE DISCUSSION OF 55 YEAR OLD FEMALE WITH CHEST PAIN, PALPITATIONS ,SHORYNESS OF BREATH AND BILATERAL PEDAL EDEMA

     By SIRIGI MOUNIKA ROLL .NO 160.8TH SEMESTER 

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

You can find the entire real patient clinical problems in the following link:https://himabindu5.blogspot.com/2020/05/hello-everyone.html

FOLLOWING IS MY ANALYSIS OF THIS PATIENT'S PROBLEM:

ORDER OF PRIORITY OF PATIENT PROBLEMS ACCORDING TO MY ANALYSIS ARE:

  • Chest pain 
  • Palpitations 
  • Shortness of breath 
  • Bilateral pedal edema upto ankle 
  • Decresed urine out put.
My analysis on each symptom with which patient came:

       CHEST PAIN 
  • Since two months 
  • On left side more on epigastrium 
  • Non radiating type
CAUSES OF CHEST PAIN:
  • Cardiac problems: Myocardial infarction, Myocardial ischemia ( angina) , myocarditis, pericatditis , mitral stenosis. 
  • Pulmonary problems: pulmonary embolism, pulmonary hypertension , tuberculosis 
  • GIT  problems: peptic ulcer disease , gallbladder disease, esophageal reflux
  • Musculoskeletal : Osteoarthritis, intercostal muscle injury, rib injury or fracture, vertebral fracture, costochondritis 
  • Neurological: Herpes zoster
EVALUATION OF THE CAUSE: 
  • Cardiac: MI : is ruled out troponin -1is -ve .
           Other causes like pericatditis, myocarditis are sudden in onset. So, these are ruled out.

The cause may beMIRAL STENOSIS  as mitral valve shows calcification and fish mouth appearance in 2D ECHO. 

  • Pulmonary: pulmonary embolism and pulmonary hypertension are also sudden  in onset .So, ruled out. But pulmonary artery hypertension secondary to heart failure may be the cause. 
There is no history of truma to the chest and no history of herpes zoster .So,neurological origin is ruled out 
  • No history of GI  disease.
PALPITATIONS:
  • Since two months associated with chest pain and shortness of breath. 
CAUSES:
  • Cardiac 
  • Emotional stress 
  • Anxiety 
  • Hyperdynamic states like anaemia, pregnancy, tyrotoxicosis.
EVALUATION OF THE CAUSE:




In this patient on examination: 
Pulse : irregularly regular, which may indicates atrial  fibrillation , confirmed by absent of 'p' waves and irregular rhythm in ECG.

Atrial fibrillation are secondary to mitral stenosis in this case which is confirmed by 2D ECHO. 

SHORTNESS OF BREATH:
  • Since two months 
  • Progressive in nature 
  • Previously it was NYHA 3 , now it is NYHA 4.
  • Associated with paroxysmal nocturnal dyspnea. Which is more severe since 10 days.
Causes:
  • Cardiac
  • Respiratory
  • Anemia
  • Renal
  • Metabolic
  • Neuromuscular
  • Drugs
Evaluation of the cause:
  • Respiratory: in this patient wheeze heard on right side and coarse crepitations more on right side of chest.These are due to pulmonary hypertension secondary to mitral stenosis. 
  • No history of periorbital edema.but decreased urine output.but creatinine levels are normal. So renal cause is excluded. 
  • No significant usage of drugs. 
  • No muscle weakness, numbness and tingling sensation. So, neuromuscular cause is excluded. 
Thus in this case main pathology likely to be cardiac which is confirmed by 2D echo. 
   Other investigations are:
  • 2D ECHO 
  • ECG 
  • CBP
  • LRT
  • RFT
  • HEMOGRAM 
PEDAL EDEMA:
  • Since two months 
  • Bilateral 
  • Upto ankle 
Causes:
  • Cardiac disease 
  • Renal disease 
  • Liver disease 
  • Thyroid disease. 
  • Malnutrition 
  • Lymphedema 
  • Medication: NSAIDS, CALCIUM CHANNEL BLOCKERS, CORTICOSTEROIDS.
Evaluation of the cause:
  • Already renal cause is excluded in this patient. 
  • No drug history 
  • No abdominal distention. So,malnutrition is excluded. 
  • No history of ascites.so, liver cause is excluded. 
By this time I came to know it is cardiac pathology which  causes the symptoms of the patient.

ANATOMY AND PATHOPHYSIOLOGY IN THIS CASE:

Compensatory mechanisms by body in heart failure:



In this patient initially there is mitral stenosis then it progressively leads to cardiomyopathy, dilation of chambers. 
TREATMENT:
1.INJ.LASIX 2amp in 50ml NS @8mg/hr
2.oxygenation to maintain spO2 above 95%
3.nebulization with budecort 12th hourly
4.strict I/O charting
5.monitoring BP,PR hourly
6.fluid and salt restriction
7.head end elevation
8.inj.amiodarone 300mg (2amp) at 6ml/hr
9.inj.pantop 40mg/OD/iv
10.T. ecosprin 75mg/PO/OD
Treatment suggested
  • ACE INHIBITORS 
  • ARB'S
  • BETA BLOCKERS 
1.INJ.LASIX 2amp in 50ml NS @8mg/hr
2.oxygenation to maintain spO2 above 95%
3.nebulization with budecort 12th hourly
4.strict I/O charting
5.monitoring BP,PR hourly
6.fluid and salt restriction
7.head end elevation
8.inj.amiodarone 300mg (2amp) at 6ml/hr
9.inj.pantop 40mg/OD/iv
10.T. ecosprin 75mg/PO/OD
Other treatment suggested are:
1.ACE INHIBITORS 
2.ARB'S
3.BETA BLOCKERS 
Mechanism of action of drugs used in heart failure:
REFERENCE:
1.https://himabindu5.blogspot.com/2020/05/hello-everyone.html
2. davidson principle's of medicine
3. https://m.youtube.com/watch?v=Rrc5r1MFZ2Y&feature=youtu.be
4.https://m.youtube.com/watch?v=zzxTuzdUvwA&feature=youtu.be

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