Hello all, iam an Intern, and this is a case history of one of our patient's who got admitted . This is to complete my log book as a part of internship duty
14/01/2020
A35year male presented with complaints of shortness of breath since 2weeks and pedal Edema since 2weeks
Patient was apparently asymptomatic 1month back then he developed fever ,associated with chills ,which is high grade for which he took treatment at local rmp where he was given anti malarial drugs and treated symptomatically after which patient felt better currently from 2weeks he is complaining of b/l pedal edema ,extending up to knees ,pitting type,progressing in nature shortness of breath from 2weeks ,initially NYHA 3 after treatment now grade 2 h/o paroxysmal nocturnal dyspnea and generalised weakness from 2weeks
No h/o fever ,vomitings ,abdominal distension ,diarrhoea ,cough,cold
PAST HISTORY :
No history of similar complaints in the past
Not a known case of DM ,HTN,Epilepsy,CVA,CAD
PERSONAL HISTORY :
mixed diet with normal appetite and normal bowel&bladder habits
H/o alcohol and smoking occasionally
No significant family history
GENERAL EXAMINATION:
well built and well nourished
Afebrile
Pallor absent
Noicterus,cyanosis,clubbing,lymphadenopathy
Edema upto knees (grade2)
BP:130/80mmhg
PR:80bpm
CVS:s1s2heard
RS:right ISA early inspiratory crepts +
P/A:soft and non tender
CNS:Hmf normal
Cranial nerves intact
Motor system normal
Sensory system normal
No cerebellar signs
JVP of this patient
https://drive.google.com/file/d/1Gr2xuU5bcPUbNmQaPjVIavwn1m-FK7gr/view?usp=drivesdk

INVESTIGATIONS:
Heamoglobin :15.2
Tlc:9600
Platelet:2.39
FBS:102
PLBS:205
Total cholesterol:150
Triglycerides:87
Hal:33
LDL:72
Vldl:17.4
Urea:24
Creatinine:0.8
Uric acid :6
USG abdomen:right moderate pleural effusion ,grade1 fatty liver,mild ascites
2D ECHO:EF-27%,IVC dilated(2.3cm)not collapsing,mild TR+,severe MR+,trivial AR+,dilated all chambers ,global hypokinesia,severe LV dysfunction,mild PAHT,no MS/AS,no PE/LV clot
DIAGNOSIS: heart failure with reduced ejection fraction secondary to viral myocarditis with denovo DM type 2
TREATMENT:
Tab.lasix 80mg...40mg...40mg
Tab.isosorbide mononitrate10mg bd
Tab.hydralazine 25mg
Tab. Telma20mg
Tab.metformin 500mg po od
Fluid restriction <1litre/day
Salt restriction <2gms/day
On 14/5/2020
Patient came for opd with complaints of pedal odema and shortness of breath since 1week
Patient is investigated for 2d echo and findings are: left ventricular dilatation ,left atrial dilatation,end point septal separation distance is increased,right atrial and ventricular dilatation ,global hypokinesia
Based on the above findings we have increased the dosage of vymarda 50mg BD (sacubitril 26mg +valsartan24mg) to vymarda to 100 mg BD
PROCEDURE:
I have seen the 2D ECHO of this patient today
https://drive.google.com/file/d/1K9Fk66l6c79ziOF-dIYQ3vDlGbSavlr7/view?usp=drivesdk
NEET TOPIC :
Myaesthenia gravis:
It is a neuromuscular diseases that lead to varying degrees to skeletal muscle weakness.
Pathophysiology:
T cell and B cell mediated activation leads to production of antibodies which causes
a)Decrease in number of acetylcholine receptors in the post synaptic membrane
b)acetylcholine cannot bind to receptors
Antibodies : such as
1)anti acetylcholine receptor antibody
2)anti musk antibody
Presenting complaints:
Starts with ocular weakness or pharyngeal weakness followed by generalised weakness (mainly proximal muscles of lower limb)
Management :
Investigations:
1)ice pack test
2)tensilon test
3)repetitive nerve stimulation tests
4)single nerve fibre electromyography
Treatment:
a)pyridostigmine:30-60mg 6th hourly later taper off
Relapse- steroid +azathioprine
Crisis- IvIg and plasma exchange
b) thymectomy.
Nice presentation 👍
ReplyDeleteVery useful
ReplyDeleteMam..can we get chest x-ray and beta natriuretic peptide (BNP) reports in this patient?
ReplyDeleteAnd also mam.. can we get cardiac MRI if possible to know the etiology of heart failure?
ReplyDeletemaam is this cardiomyopathy post a viral infection like cocksackie B
ReplyDeleteif so why are the chambers of the heart enlarged
wouldn't we be expecting an inflammation of the myocardium which is in most cases self resolved in viral myocarditis
and can we account for such acute cardiac involvement
Mam can we get his last HbA1c, FBS,and ppbs reports?
ReplyDeleteMam does the edema has any diurnal variation??
ReplyDeletebut according to the hisory the patient is not a known case of DIABETES MELLITUS type 2
ReplyDeleteMa'am, are the crepitations in this patient coarse or fine?
ReplyDeleteOn calling up the patient and asking further doubts:
ReplyDelete[01/06/20, 10:39:20 AM] Shri Valli: Sir I just had a conversation with the DCM patient sir.
[01/06/20, 10:39:37 AM] Shri Valli: He told me that he used drugs related to malaria for 10 days
[01/06/20, 10:40:18 AM] Shri Valli: And his dosage was twice a day.
He apprently doesn't have the prescription or any remaining strip of the medicine.
[01/06/20, 10:40:57 AM] Shri Valli: He remembers being able to work for 2 months after the fever and medication.
I. E in Oct Nov
[01/06/20, 10:41:45 AM] Shri Valli: From December 20th, he faced weakness.
And his pedal edema seemed to be less in the morning and progressed during the day time.
[01/06/20, 10:42:41 AM] Shri Valli: On asking his present condition, he says he feels weak and attributed it to the heat.
On asking about his activity, he says he's at home and is feelings dyspneic even on walking in the house, on waking up and before going to sleep.
[01/06/20, 10:43:12 AM] Shri Valli: He's also taking his anti diabetic medication regularly and is keen to come for his check up next week.
History updated today by Dr Aashita PGY2 below:
ReplyDelete35 year old man working as a food caterer from
presented to our OPD with the complains of :
Dyspnea since 5 days
Cough since 5 days
Bilateral pedal edema since 4 days
Followed by
abdominal distension since 3 days
Patient was born and brought up in xxxx . He was born to a farmer and a housewife and has 2 siblings, an elder sister who is a houswife and has been married to an advocate and an elder brother who is a software engineer. He has completed his degree in electronics and has been working as a food caterer in xxxx the last 10 years. In these last 10 years he has been regularly consuming alcohol around 180 ml of whiskey everyday along with his other friends. He says he used to sometimes feel lonely and he decided not to get married unless the financial situation of his family settles.
He was apparently completely alright until December 2019 when he developed dyspnea which was sudden in onset and was associated with occasional cough on and off and was also associated with bilateral pedal edema and abdominal distension. He says his dyspnea used to aggravate on exertion and it wasnt associated with chest pain, palpitations, hemoptysis or reduced urine output. Though he tells it used to aggravate on laying position.
He was taken to a hospital in xxxx where they put on some unknown medications for 10 days. He visited our hospital as his symptoms didn't relieve with those medications.
He was admitted in our hospital for few days and was diagnosed with dcmp with an ejection fraction of 36 %. His HbA1c was found to be 8.4 and was diagnosed as type 2 DM and the patient was started on OHAs and was stopped on OHAs after 3 days. He was advised to get an angiogram done.
He visited NIMs hospital where CAG was done and was reported as normal. He was started on Ecosprin, Tab Vymada ( valsartan and sacubitril), Dytor plus 10/20. He stopped taking ecosprin after 2 months and was advised to even take oral form of Lasix 40mg twice a day on regular visits to our hospital.
He now presented to us, dyspneic with a respiratory rate of 27 cpm and tells us he has been dyspneic the last 5 days which aggravated especially on climbing stairs and on laying on the bed associated with occasional cough with scanty mucoid non blood tinged sputum. In the past 4 days he has even developed bilateral pedal edema followed by abdominal distension.