The active learning session below was initiated by the treating unit PG before the treating unit intern collated the patient information into his E log here: https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1
[5/19, 5:13 PM] Kims Aditya Samitinjay: A 30 year old shepherd from Gopanatlapuram presented to the OPD with complaints of Dyspnea and pedal edema since 15 days.
An able shepherd who finished schooling till Class 7 and eventually pursued his current occupation with his father, the patient had been having a fairly fulfilling life until last October when he first reported breathlessness while taking the herd atop a molehill. He remembers the event as he felt scaling this molehill was quite easy for him before but this time he felt breathless and had to rest for a while to catch up his breath. Retrospectively he says that he had a feeling of suffocation and felt relieved after a few minutes in the shade.
The patient also reported that such events have been progressive since October and that on quite a few occasions he felt heavy pounding palpitations in the middle of his chest. He says that these palpitations too were exertional and relieved with rest. He also reported that he occaskknally felt very dizzy with near blacking out associated with profuse sweating. All feature subsided with rest. He never had overt LOC. Specifically, he did not have this with prolonged standing in the sun. No history of nausea or vomiting during these dizzy spells. Patient denies fatigue and thoroughly enjoyed going to work and spending time in the fields.
The patient reported that from March this year he also started having dry cough without any expectoration. He also reported nocturnal wheezing, usually at around 4 am. It was never severe to wake him up from his sleep.
With Dyspnea fast catching up and impairing his productivity, the patient stopped working for a while and visited his sister's place 15 days ago when she noticed that he was unusually becoming breathless on walking short distances. She also admitted that the patient was wheezing at around the same time he mentioned. However she noticed that it did not wake him up from his sleep.
The patient reported that he has been having pedal edema for the last 15 days. And at this point it prompted him to consult us.
The patient is the youngest of 2 siblings with a very concerned and caring sister. He lives with his mother who is unemployed and depends on him. His father passed away years ago and he says he was a chronic alcoholic. Apart from these symptoms, he never had urinary or bowel disturbances. He has a fairly mixed diet and has a good appetite. His main concern now though is dyspnea and pedal edema limiting his quality of life.
[5/19, 5:13 PM] Kims Aditya Samitinjay: Analysis and inputs and queries welcome.
[5/19, 5:16 PM] Vivek Poddar 3: Alcoholic Cardiomyopathy, LVF, Cardiac asthma, pedal edema due to cardiac failure!
[5/19, 5:19 PM] Vivek Poddar 3: Why profuse sweating and palpitations! Indicating over activation of sympathetic nervous system
[5/19, 5:20 PM] Vivek Poddar 3: Pedal edema could be due to primary lung cause leading to cor pulmonale or secondary to left heart failure with right ventricular failure. Alcoholic might have been responsible for Cardiomyopathy leading to LVF or atrial fibrilation?
[5/19, 5:22 PM] Vivek Poddar 3: But he remember the event when it all started, indicating acute onset?
[5/19, 5:23 PM] Vivek Poddar 3: Subsiding with rest suggesting a vascular insufficiency in the heart!
[5/19, 5:24 PM] Vivek Poddar 3: How about the JVP and cardiac and respiratory auscultatory findings?
[5/19, 5:25 PM] Vivek Poddar 3: Any other comorbid conditions?
[5/19, 5:25 PM] Vivek Poddar 3: What's his BMI?
[5/19, 5:27 PM] Kims Aditya Samitinjay: No history of PND or Orthopnea. Epidemiologically, age and short duration of progression make LHF unlikely ?
[5/19, 5:27 PM] Vivek Poddar 3: But cardiac myopathy is not unlikely?
[5/19, 5:28 PM] Kims Aditya Samitinjay: Not necessarily, I still remember the day I was very febrile and was diagnosed with 'Typhoid'. Possibly it overwhelmed him.
[5/19, 5:28 PM] Kims Aditya Samitinjay: No comorbids as such.
[5/19, 5:28 PM] Kims Aditya Samitinjay: About 22.
[5/19, 5:29 PM] Kims Aditya Samitinjay: Yes it's elevated. Will reveal those findings in a detailed monolgue.
[5/19, 7:03 PM] Rakesh Biswas: Alcoholic? 🤔
I thought that was his father?
[5/19, 7:03 PM] Rakesh Biswas: Yes happens in heart failure 👍
[5/19, 7:06 PM] Rakesh Biswas: Very well written narrative and has the potential to become a global health case report.
However need more data to find out the etiology of his heart failure.
Also I am not sure if a mole hill is large enough to be scaled by a human. You probably meant mound that would go for a small hill
[5/19, 7:14 PM] Vivek Poddar 3: Oh, I read he is. It was his father
[5/19, 10:17 PM] Kims Aditya Samitinjay: On examination, the patient was in no apparent distress and he was oriented to time place and person.
The patient appeared slightly undernourished with thin and lightly underpigmented hair with a normal hairline. He appeared to have a mild conjunctival pallor with no icterus or obvious nasal abnormalities. He tongue was red with no apparent features of cyanosis or other lesions. Speech was intact was normal conversational abilities. There were no obvious deformities of the neck and chest or back. Clubbing, koilonychia or leuchonychia were absent. Lower limbs were remarkable for significant bilateral pitting type of pedal edema which extended upto the knees. No cervical or axillary lymphadenopathy was noted.
[5/19, 10:21 PM] Kims Aditya Samitinjay: Sorry I missed the vitals here - PR 118 bpm BP 110/70 Temp Afebrile and RR 20. Spo2 97 on room air.
[5/19, 10:22 PM] Kims Aditya Samitinjay: GRBS at 145 with FBS 114 and HbA1c 6.5.
[5/19, 10:22 PM] Vivek Poddar 3: So, is it all because of malnutrition causing anemia, shortness of breath, pedal edema (due to low albumin)?
[5/19, 10:22 PM] Kims Aditya Samitinjay: Hb 10.4 with a N/N picture. Albumin at 3.9.
[5/19, 10:24 PM] Vivek Poddar 3: though anemia can occur with normal albumin
[5/19, 10:24 PM] Vivek Poddar 3: I mean edema can*
[5/19, 10:24 PM] Vivek Poddar 3: but it is a mild anemia
[5/19, 10:24 PM] Kims Aditya Samitinjay: Yep the patient had a raised JVP. Video will be shared tomorrow morning.
[5/19, 10:25 PM] Vivek Poddar 3: How about the red cell indices?
[5/19, 10:26 PM] Kims Aditya Samitinjay: I will share pictures of his reports as soon as possible
[5/19, 10:26 PM] Rakesh Biswas: CVS examination findings?
[5/19, 10:29 PM] Kims Aditya Samitinjay: Apical impulse visible. Confirmed with palpation at 5th ICS within the MCL, I felt it was foreceful and well sustained, localising to 1 ICS. RV heave + and I felt he had a loud P2 and RVS3. I don't know how and why but I'm strongly positive he had a holosystolic murmur in the pulmonary area yesterday which seems to have disappeared today. The only therapeutic intervention given was Lasix 40.
[5/19, 10:30 PM] Rakesh Biswas: Grade of the murmur?
[5/19, 10:30 PM] Kims Aditya Samitinjay: His JVP was elevated, 11 to 12 cm and had a prominent a wave with Vy collapse.
[5/19, 10:31 PM] Kims Aditya Samitinjay: Wasn't palpable sir. So 3/6. Could palpate a heart sound at the pulmonic area though.
[5/19, 10:31 PM] Rakesh Biswas: TR likely?
[5/19, 10:32 PM] Kims Aditya Samitinjay: Possible sir. Not sure why it disappeared.
[5/19, 10:33 PM] Vivek Poddar 3: disappeared mean it never reappeared then?
[5/19, 10:35 PM] Kims Aditya Samitinjay: Well he was admitted yesterday. It was there yesterday and seems to have gone today.
[5/19, 10:36 PM] Vivek Poddar 3: He was given lasix yesterday it seems?
[5/19, 10:38 PM] Vivek Poddar 3: Reduced preload should decrease the flowthrough stenotic and regurgitant valves and thus the murmurs will decrease except for MVP and HOCM
[5/19, 10:38 PM] Kims Aditya Samitinjay: Yes one dose of 40mg at 8pm.
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