Tuesday, January 13, 2015

Long Case with Dr. Anis

Patient 1

Madam Z, a 55-year-old Malay female with underlying hypertension and Type 2 Diabetes Mellitus, presented with painless bilateral leg swelling and worsening shortness of breath for one month duration. It was associated with paroxysmal nocturnal dyspnoea, orthopnoea and reduced effort tolerance.

Physical examination showed an obese patient with bilateral pitting edema. There was no finger clubbing, no stigmata of infective endocarditis or chronic liver disease and no facial puffiness. Cardiovascular examination revealed raised JVP. Apex beat was not palpable. First and second heart sounds were heard with no murmur.

1. Provisional diagnosis?
Decompensated congestive cardiac failure

2. Other differential?
Chronic kidney disease

3. Signs and symptoms of right heart failure?
Fluid overload such as pleural effusion and ascites

4. Signs and symptoms of left heart failure?
Pulmonary congestion causing pulmonary oedema, dyspnoea, orthopnoea, PND

5. One investigation to diagnose heart failure?
ECHO where we can assess:
  • Ejection fraction (we look at end diastolic volume, how many stroke volume, if less than 60% = heart failure)
  • Size of ventricles (wall hypertrophy, dilated ventricle)
  • Function of ventricles (region wall motion abnormalities)
  • Valves (vegetation, thrombus, abnormality)

6. Signs of pulmonary oedema on CXR?
  • Bats wings sign (alveolar oedema)
  • Kerley B sign (interstitial oedema)

7. Signs of heart failure on CXR?
  • Cardiomegaly
  • Prominent upper zone dilated vessels
  • Bats wings sign
  • Kerley B lines
  • Pleural effusion

8. Causes of heart failure?
  • Ischemic
  • Intrinsic - cardiomegaly
  • Extrinsic - Pericarditis
  • Valvular heart disease
  • Hypertension - cor pulmonale, systemic hypertension

9. Antihypertensive and heart medications in this patient?
  • Amlodipine - Calcium channel blocker (SE : pedal edema, reflex tachycardia)
  • Perindopril - ACE inhibitor (SE : cough due to bradykinin release in lung)
  • Metoprolol - Beta blocker (SE : worsens asthma, urticaria, psoriasis, PVD, ED)

10. Diuretics that you know of?
  • Frusemide - Loop diuretic (MOA : acts on Na K ATPase, SE : hypokalemia, nephrotoxic)
  • Spironolactone - Potassium sparing diuretic 
  • Hydrochlorothiazide - Thiazide diuretic

11. Oral hypoglycaemic agents in this patient?
  • Metformin - Biguanide (MOA : reduce hepatic glucose production and increase peripheral uptake of glucose and increase insulin sensitivity, SE : weight loss)
  • Gliclazide - Sulphonylurea (MOA : Increase insulin secretion, SE : Weight gain, hypoglycaemia)

12. Other OHA that you know of?
  • Non-SU - Meglitinide
  • Alpha glucosidase inhibitor - Acarbose
  • Thiazolidinedione - Rosiglitazone
  • DPP-4 inhibitor - Sitagliptine
  • ALP-1 agonist - Exenatide

13. Type of respiratory failure?
  • Type 1 : hypoxaemia only
  • Type 2 : hypoxaemia and hypercapnea  

14. Physical signs of carbon dioxide retention?
  • Flapping tremor
  • Central cyanosis
  • Warm periphery
  • Bounding pulse


Patient 2

Madam B, a 63-year-old Malay female with underlying Type 2 Diabetes Mellitus, non-compliant to medications for the last 2 months, above knee amputation of left lower limb and metatarsal amputation of right toes, presented with one week history of right leg swelling up to knee and five days history of shortness of breath and non-productive cough. BP was high on admission. There was no orthopnoea, PND and no uremic symptoms.

On examination, patient had urinary catheter. Mild pallor was noted. Left leg stump was well-healed. Right leg pitting oedema was noted up to sacral region. Patient afebrile, BP 150/80 mmHg. HR 82 bpm. RR 16 bpm. On abdomen examination, abdomen soft and tender, not distended. Shifting dullness was positive, no fluid thrill. No hepatosplenomegaly.

1. Provisional diagnosis?
Fluid overload secondary to chronic renal failure or diabetic nephropathy

2. Other differential?
Congestive heart failure, but not likely because JVP was not raised

3. Signs and symptoms of renal failure?
  • Fluid overload - facial puffiness, abdominal swelling, pedal oedema
  • Anaemia - palpitation, shortness of breath, dizziness, syncopal attack
  • Uraemia - nausea and vomiting, lethargy, itchiness, confusion, seizure
  • Parasthesia

4. Management?
  • Acute - reduce blood pressure, reduce fluid overload, start insulin, IO chart, ROF 800cc/day
  • Long term - antihypertensive, patient education on compliance, restriction of salt and protein intake, refer dietician, diabetic diet, refer wellfare for prosthetic 

5. Disadvantages of insulin injection?
  • Injection, must be monitored
  • Risk of hypoglycaemia
  • Risk of atrophy and infection at injection site

6. Types of insulin?
  • Short-acting - 20 to 30 minutes onset, effect continues until 4-6h, eg. Actrapid, inject before breakfast, before lunch and before dinner
  • Intermediate-acting - eg. Mixtard 30/70, inject once in morning before breakfast once before dinner, disadvantage is less fine control of infusion rate
  • Long-acting - effect starts later 2-3h, persists up to 12h, eg. Glargine, inject one before bed

7. Types of dialysis?
Haemodialysis and Peritoneal dialysis

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