A 70 YR OLD MAN WITH ENLARGED HEART
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Here is a case I have seen :
Unit 3
Interns-
Harsha
Sreeja
Archana
Kalyan
Sahithi
Jeeharika
Dr Raveen - PGY1
Dr Chandana - ICU PG
Dr Aashitha - PGY2
Dr Aravind - PGY3
Dr Vamshi - PGY3
Dr Hareen - SR
Dr Praveen Naik - Ass Prof
Introduction
Introduction:
Ischaemic heart disease occurs when the myocardial oxygen supply is does not meet the myocardial oxygen supply.
Here, we present a case of a 70 year old man with a history of CAD 2 years back with DCMP with an EF of 24%
A 70 year old man presented to the casualty with the complaints of
Bilateral pedal edema since
27 days
Abdominal distension since 25 days
Dyspnea since 20 days
Cough since 20 days
Loose stools since 7 days
Vomitings since 7 days
Patient used to work as a farmer 12 years back at Nalgonda. He is a father of 4 children. His wife passed away few years back because of? Cancer.
He gives a history of left forearm fracture 25 years back for which he got operated and a rod was placed.
12 years back he gives a history of a heavy object falling on his right foot while he was working at the farm.
10 years back he gives a history of trauma to his left little finger.
Since the past 4 years, he started experiencing Dyspnea on exertion, he would often feel Dyspneic on walking for short distances, he gives a history of bendopnia, he says he occasionally had episodes of chest pain along with palpitations and giddiness on and off.
He also says he would often develop bilateral pedal edema on and off which would resolve on its own. He gives no history of orthopnea, PND.
After 2 years, he decided to visit a hospital after experiencing severe chest pain after which he had a cardiac stent placement for a ? Single vessel. He continued using medications prescribed by the hospital for 6 months and was apparently asymptomatic then. 6 months later he started redeveloping the same symptoms after stopping medications. He often developed bilateral pedal edema along with Dyspnea on exertion on and off.
27 days back, he developed bilateral pedal edema extending upto knees and abdominal distension. He started experiencing dyspnea at rest gradually to such an extent that he started finding it hard to sleep and would often get up from his sleep.
Since 20days, he has been having productive cough with mild expectoration with no hemoptysis, non foul smelling
Since 7 days he says he has been having frequent episodes of small stools, not associated with any tenesmus, around 4-5 episodes per day, non blood tinged. He also has been having 4-5 episodes of vomitings, containing food content.
Since 2 days he says he has been having reduced urine output
History of weight loss around 5 kgs over last 2 years.
He was a regular toddy drinker 10 years back for 35 years.
On examination:
He is thin built
Pallor+
Bilateral pedal edema+ extending upto knees+
PR - 120 bpm
Bp - 100/60mmhg
Afebrile
RR - 28cpm
Spo2 - 99%
JVP - raised
Chest diameter:
AP - 21cms
Transverse diameter - 25cms
Apical impulse visible+
Left parasternal heave+
Palpable P2+
Epigastric pulsation +
Apex beat in 6th ICS 1 cm lateral to MCL
On Ausculation: Pansystolic murmur+
Lungs - inspiratory crepts in all the lung fields +
Per abdomen - tenderness in right hypochondriac region +
Investigations :-
ECG
Chest X Ray PA view
2D Echo
Serum ferritin
USG Abdomen
X-ray Both Hands
?Dilated Cardiomyopathy with EF 24%
Moderate PAH- secondary type
Acute gastroenteritis
? Rheumatoid arthritis
28/01/21
S - Pt feeling subjectively better
No Dyspnea.
O- Bp -100/70mmhg
Pr- 63 bpm
Spo2-96% on RA
I/0- 400/1150 ml
Cvs - Jvp elevated.
Apical impulse visible in left 6 th ICS later to MCL
Lt parasternal heave present
Palpable P2 present
Pansystolic murmur present
RS - Inspiratory crepts present in b/l IAA,ISA,IMA.
A- DCMP WITH EF -24%
MODERATE PAH
RHEUMATOID ARTHRITIS.
29/1/21
S - Patient says his loose stools have reduced
No episodes of vomitings since 2 days
O-
PR- 78bpm
BP - 110/70mmhg
RR - 18cpm
Spo2 at 99%
Cvs -
JVP+
Left parasternal heave +
Palpable P2+
Pansystolic murmur+
Epigastric pulsation +
Lungs - Inspiratory crepts in B/L
IAA, ISA +
Per Abdomen - tenderness in right hypochondriac region
A-
DCMP with EF 24%
Moderate PAH
History of PTCA 2 years back
Acute Gastroenteritis
Rheumatoid Arthritis
P-
Sir, he has been having productive cough since 10 days. We've sent his sputum samples.
RTPCR sample was sent yesterday, they asked us to send a repeat sample today.
Sputum for AFB report :
30/1/21
S :complaining of low grade fever since last night
No episodes of loose stools
No episodes of vomitings since 2 days
O-
PR- 82 bpm
BP - 110/70mmhg
RR - 18cpm
Spo2 at 99%
Cvs -
JVP raised
Left parasternal heave +
Palpable P2+
Pansystolic murmur+
Epigastric pulsation +
Lungs - Inspiratory crepts in B/L
IAA, ISA +
Per Abdomen - tenderness in right hypochondriac region
A:
DCMP with EF 24% secondary to ischaemic heart disease
Moderate PAH
History of PTCA 2 years back
Acute Gastroenteritis
Rheumatoid Arthritis
Anemia under evaluation
P:
RTPCR For SARS-CoV:Negative
We've sent his retic count which came to 2.6.
Retic index is 1.2 showing hypoproliferative picture.
Sending serum Ferritin today.
31/01/21
S - No fever spikes
No episodes of loose stools
No episodes of vomitings since 3 days
Though he has been complaining of giddiness on and off
O -
PR- 86 bpm
BP - 100/70mmhg
RR - 18cpm
Spo2 at 99%
Cvs -
JVP raised
Left parasternal heave +
Palpable P2+
Pansystolic murmur+
Epigastric pulsation +
Lungs - Inspiratory crepts in B/L
IAA, ISA +
Per Abdomen - tenderness in right hypochondriac region
A-
DCMP with EF 24% secondary to ischaemic heart disease
Moderate PAH
History of PTCA 2 years back
Rheumatoid Arthritis
Anemia under evaluation
P-
His ecg shows regular rate with old AWMI changes
We got his peripheral smear done which is shows ncnc with few mictocytes and tear drop cells.
His retic count is 2.6, Retic index came to 1.22 so hypoproliferative
ECG
01/2/21
S - No fever spikes
No episodes of loose stools
No episodes of vomitings since 4 days
Though he has been complaining of giddiness on and off
O-
PR- 78 bpm
BP - 110/80mmhg
RR - 18cpm
Spo2 at 98%
Cvs -
JVP raised
Left parasternal heave +
Palpable P2+
Pansystolic murmur+
Epigastric pulsation +
Lungs - Inspiratory crepts in B/L
IAA, ISA +
Per Abdomen - tenderness in right hypochondriac region
A-
DCMP with EF 24% secondary to ischaemic heart disease
Moderate PAH (secondary type)
History of PTCA 2 years back
Rheumatoid Arthritis
Acute gastroenteritis
Umbilical hernia
Anemia under evaluation
P-
Plan for review 2D echo.
03/02/21
S -
No episodes of loose stools
No episodes of vomitings
Though he has been complaining of giddiness on and off
O-
PR- 76 bpm, low volume,
BP - 110/70mmhg
RR - 18cpm
Spo2 at 98%
Cvs -
JVP raised
Left parasternal heave +
Palpable P2+
Pansystolic murmur+
Epigastric pulsation +
Lungs - Inspiratory crepts in B/L
IAA, ISA +
Per Abdomen - tenderness in right hypochondriac-right lumbar - right iliac region
A-
DCMP with EF 28% secondary to ischaemic heart disease
Moderate PAH (secondary type)
History of PTCA 2 years back
Rheumatoid Arthritis
Acute gastroenteritis
Umbilical hernia
Anemia under evaluation
P-
Planned for referral for urology for right abdominal pain (loin to groin) in view of renal/ureteric calculus
Discussion:
The reason for the patients DCMP is secondary to ischaemic heart disease. He also has been an alcoholic and was on a chronic use of NSAIDs.
He also has anemia with a hemoglobin of 9g/dl which further aggravate heart failure , even though not so low, as the myocardial oxygen supply will reduce in anemia
The patient also has multiple joint pains with the characteristic description of 'early morning joint stiffness lasting for half an hour' since the past 10 years. He also has the characteristic Z deformity and piano key deformity.
http://calgaryguide.ucalgary.ca/overview-of-ischemic-heart-disease/
https://www.sciencedirect.com/topics/medicine-and-dentistry/heart-failure-with-reduced-ejection-fraction
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