MEDICINE CASE

DISCUSSION- 5
GROUP 2
 GROUP MEMBERS
1.KIRAN GADALE
2.SWATHI TIRUMALASETTY
3.PAVAN RAHUL BAKKAMUNTHALA
4.ISHITA DIWAN
5.RIDDHI MAKRUBIYA
6.SELSI DALIYA
7.DHARA SHAH
8.HASHMI NAZIA AFREEN
9.THOTA VAMSI
10.VINEELA MANDAVA
11.MOHIT MAVANI
12.SANJANA SEN SARMA
 GENERAL DATA
● Name: Sison ● Date of interview : 26-sep-2024
● Age: 55 yo ● Time of history taking : 10.15am
● Gender: Male ● Informant : Patient daughter
● % Reliability : 100%
● Civil status: Single
● Religion: Roman catholic
● Nationality :Filipino
● Address: Mangatarem ,Pangasinan
● Birthdate: Sep 18th 1969
● Occupation: vegetable vender
● Date of admission: sep 22 2024
● Time of admission: 2:00 PM
CHIEF COMPLAINT
DIFFICULTY OF BREATHING
HISTORY OF PRESENT ILLNESS
1 month PTC: The patient noticed difficulty in breathing while
walking. with no other associated symptoms observed like
chest pain,fever,cough.
Interim, No worsening of symptoms, only persistent symptoms
as previously mentioned

5 days PTC: During the night, the patient experienced

worsening shortness of breath and noted a scrotal bulge with
a pain severity of 7/10. He was unable to walk for long
distances. No medications were taken,no consultation was
sought.

4 days PTC: The patient consulted Blessed Family Doctors

General Hospital in San Carlos, where he was prescribed
painkiller and advised to go to a bigger hospital. However, he
refused hospitalization and returned home. 5
3 days PTA: The same symptoms persisted, and the patient noticed
whitish discharge from the scrotum along with tenderness and pain
rated 9/10. He also had a non-productive cough and no consultation
was done.

2 days PTA: The patient developed a productive cough with white

phlegm,low-grade fever of 38°C, which was intermittent.. Pt self
medicated paracetamol 300 mg for every 6 hrs, as well as continued
whitish discharge from the scrotum. No medical consultation was
sought.

1 day PTA: The above symptoms are persisted, and after being
convinced by his big sister, he decided to seek consultation at R1MC
Arellano.
PAST MEDICAL HISTORY
➢ The patient was diagnosed with diabetes and hypertension at the age of
38.

➢ No history of adult illnesses such as , Stroke, Asthma, TB, or any other

Cardiovascular problems

➢ Completely vaccinated for BCG, DPT, Polio, Hepa B, and Measles.

➢ No history of childhood illness like Rheumatic fever, chicken pox, polio,

measles & mumps.

➢ No known allergies to foods, medications, pollen, or animals.

➢ No history of any previous surgical procedures and hospitalizations.

 REVIEW OF SYSTEMS
Constitutional: (-) Chills (+) weight gain (3kg),(-)fatigue
●Skin: (-) Rashes (-) Itching (-) Lumps (-) Dryness (-) Color change (-) Changes in
nails
●Hair: (-) Baldness (-) Excess hair
●Head: (-) Tenderness (-)Dizziness (-) Lightheadedness (-) Trauma
●Eyes: (-) Pain (-) Redness (-) Double vision (-) Blurred vision (-) Use of
glasses/lenses (-) Lacrimation
●Ears: (-) Hearing problem (-) Earache (-) Discharge (color/consistency) (-) Itching
●Mouth & Throat: (-) Use of dentures (-) Mouth sores (-) Bleeding gums (-) Sore
throat Hoarseness (-) Dysphagia
●Neck: (-)Pain (nuchal) (-) Stiffness (-) Lump
●Respiratory: (-) Sputum (-)cough (-) Hemoptysis (-) Wheezing
Cardiovascular: (+)Chest pain (-) Palpitations (+) Orthopnea (+) Edema (-) Cyanosis
(-)Paroxysmal Nocturnal Dyspnea (-) Easy Fatigability
●Homatologic: (-) Easy bruising, (-)pallor, (-)bleeding
●Gastrointestinal: (+) Loss of appetite (-) Nausea (-) Hematemesis (-)Dysphagia
(-)Hematochezia (-) Diarrhea (-)Hemorrhoids (-) Constipation (stool characterized as
hard in consistency)
●Renal: (-) Dysuria (-) Oliguria (-) Polyuria (-) Nocturia (-) Gross Hematuria (-)
Incontinence
●Urinary Retention (-) Urinary Urgency (-) Tea-Colored urine
●Musculoskeletal: (-) muscle weakness, (-) stiffness, (-) backache, (-) joint swelling.
(-)muscle pain, (-) joint pain
●Neurologic: (-) paralysis, (-) tremors, (-) memory loss, (-) numbness, (-) seizures
●Peripheral vascular: (-) leg cramps, (-)varicose veins
● Psychiatric: (-) Insomnia, (-) Depression, (-) Mania, (-) Anxiety, (-) panic attacks
 FAMILY HISTORY
❖ Patient father is deceased due to old age and his mother (75 year
old ) is alive and no illness
❖ Patient has 9 siblings, 2 sisters have hypertension
❖ Patient have 8 children , all healthy
❖ No history of heredofamilial diseases like cancer, thyroid, asthma,
blood disorders noted.
 PERSONAL AND SOCIAL HISTORY

● Number of years married: 32 years

● Patient has 8 children. All are healthy.
● High school graduate.
● His occupation was vegetable vendor and no occupational hazard.
● He does not smoke.
● Drinks alcohol occasionally.
● Patient eats 3 times a day
● Patient food preference vegetables, eggs, chicken.
● He takes coffee 2 times a day
For The LIVING CONDITION of the patient
● Currently residing bamboo type house with 2 rooms in
mangatarem pangasinan since 2006
● There are currently 8 occupants (patient, wife and 5
daughters and 1 grand daughter )
● The source of drinking water is mineral.
● The garbage is collected by barangay.
● Patient denied owing any pets.
● The state of the neighbourhood is good.
 PHYSICAL
EXAMINATION
 PE ON ADMISSION
BP- 130/90 mmhg
Heart rate- 120 bpm
Respiratory rate - 32 cpm
Temperature -37.4 degree celsius

Chest and Lungs: symmetrical chest expansion, decreased breath sounds, crackles,
Cardiovascular: irregular rhythm,
Genitals : Swelling of scrotum,
Extremities: Grade 2 Bipedal pitting edema .
GENERAL SURVEY
Patient is lying in semi fowler's position, irritated, hooked to facemask at 8LPM, in
cardiopulmonary distress, no dehydration

VITALS SIGNS :
BLOOD PRESSURE 130/80 mmHg (elevated) HEIGHT 163cm
TEMPERATURE 36.7 C (normal) WEIGHT 70kg
RESPIRATORY RATE 34 Bpm (tachypnea) BMI 26.3 kg/m2
(Obese)
HEART RATE 115 Cpm
(TACHYCARDIA)

SPO2 82 % face mask 8 lpm

 HEAD TO TOE ASSESSMENT
HEAD: Normocephalic head, No scalp lesions and swelling or tenderness.
Symmetrical, depressions or deformities.
EYES: Symmetrical, Periorbital swelling of both eyes , red colour sclera on both
sides, Pupils are equally reactive to light, EOM movements are normal.
EARS: Symmetrical, No deformity, No tenderness or discharge, No preauricular
pits or skin tags, Pinnae is normal in shape and contour, Hearing is intact.
NOSE: Symmetrical, no nasal congestion, No obstruction and inflammation,
Normal midline septum.
THROAT & MOUTH: Lips are normal in color without any lesions and lips are moist,
no mouth sores, no bleeding gums.
NECK :
Neck is edematous, distended jugular vein, no skin changes
CHEST AND LUNGS :
● INSPECTION: Use of accessory muscles for breathing, deep and rapid breathing,
Irregular pattern of breathing.
● PALPATION: Decreased chest expansion, thrills noted at apex of heart.
● PERCUSSION: Dullness to percussion at lung bases bilaterally.
● AUSCULTATION: Crackles are heard at both lower lungs, diminished breath
sounds over lower lung fields.
HEART
● INSPECTION: Noted parasternal heaves along left sternal border.
● PALPATION: Apex beat was diminished, palpable heaves over left second ICS
● AUSCULTATION: The first and second heart sounds were diminished, a holosystolic murmur
was auscultated at the apex of the heart radiating to axilla, characterized by a blowing
quality.
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ABDOMEN :
● INSPECTION: Abdominal distension is noted, ecchymosis noted at both flanks
● AUSCULTATION: Diminished bowel sounds on auscultation.
● PERCUSSION: Dullness on percussion at flank area , shifting dullness noted.
● PALPATION: tenderness in epigastric area, liver can be palpated
EXTREMITIES:
Grade 1 bipedal edema, weak peripheral pulses and ecchymosis on calves which was
not warm to touch and pus filled ulcer formation without discharge. symmetrical
upper and lower extremities and CRT<2 sec.

GENITALIA : IFC is placed, noted gross hematuria in urine bag.

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 Neurological examination

MENTAL STATUS : - The patient is coherent, conscious, oriented to place and

time, signs of distress, manner of speaking is normal, gait and facial
expressions are normal.

Eye opening Verbal response Motor response

4 5 6

Here, GCS SCORE = 15 ( E4V5M6)

 NEUROLOGICAL EXAMINATION

CRANIAL NERVES:
CN 1: Smell is intact
CN 2: Visual acuity is normal
CN 3,4,6: EOMs intact, no ptosis, pupils are round and reactive to light and accommodation.
CN 5 : Clenching, mastication, chewing is normal
CN 7: No facial asymmetry
CN 8: Intact hearing
CN 9,10: Intact gag reflex, uvula is in midline, good swallowing.
CN 11: Able to move head from side to side and can shrug shoulders against resistance
CN 12: Tongue is in midline
 SALIENT FEATURES
SUBJECTIVE DATA OBJECTIVE DATA

● 55y/o, male, presenting ● In cardiopulmonary distress, irritated

with difficulty of breathing ● Hooked to oxygen mask at 8LPM
● low grade fever of 38 ● Obese patient
degrees ● 130/80 mmhg (elevated)
● Productive cough with ● RR: 34 bpm (tachypnea)
● HR: 115cpm (tachycardia)
phlegm
● SPO2: 82% face mask 8 LPM (hypoxemia)
● Bulging of scrotum with ● Periorbital swelling of both eyes , red colour sclera on both
whitish discharge ● Distended jugular vein
● (+) weight gain, (+) chest ● Gross hematuria
pain, (+)orthopnea, (+) ● Use of Accessory muscles for breathing
bipedal edema, (+) loss of ● Thrills noted at apex of heart
appetite ● Dullness on percussion of chest
● Crackles are heard at both lower lungs
● Diminished bowel sounds on auscultation.
● Dullness on percussion at flank area , shifting dullness noted.
● tenderness in epigastric area, liver can be palpated
● Grade 1 bipedal edema, weak peripheral pulses and ecchymosis on
calves which was warm to touch and pus filled ulcer formation
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without discharge.
 INITIAL IMPRESSION

Pulmonary congestion due to heart failure, which is secondary to

1.Valvular heart disease

Rationale:
● Dyspnea on exertion and orthopnea due to pulmonary congestion.
● Peripheral edema and jugular venous distention due to heart failure.
● Hx of diabetes,hypertension
● Holosystolic murmur.
● Crackles in the lungs due to pulmonary congestion.
● Ascites and hepatomegaly due to systemic venous congestion.
● Wide pulse pressure
● Gross hematuria
 DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT

NEPHROTIC SYNDROME (+) Hypertension (-) Oliguria

(+) Weight gain (-) Proteinuria
(+) loss of appetite (-) Fatigue
(+) bipedal edema
(+) periorbital swelling
(+) Ecchymosis

CAP (+) Productive cough (-) High grade fever

(+) Dyspnea (-) Malaise
(+) Chest pain
(+) Tachypnea
(+) Tachycardia
(+) Hypoxemia
(+) Diminished breath sounds
(+) Crackles
(+) Lobar dullness

Pulmonary embolism (+) Dyspnea (-) Sore calf

(+) Chest pain (-) Cyanosis
(+) Cough
(+) Tachypnea
(+) Tachycardia
(+) Hypoxemia
(+) Diminished breath sounds
(+) Crackles
(+) Signs of DVT
 LABORATORY AND DIAGNOSTICS
● ROUTINE LABORATORIES :
○ CBC
○ URINALYSIS
○ COAGULATION STUDIES
○ SERUM ELECTROLYTES
● CHEST X-RAY
○ Patients with Enlarged cardiac silhouette ( cardiothoracic ratio >0.5 ) and
pulmonary venous congestion.
● ECG
● 2D ECHO
○ Most accurate and rapid determination of ventricular size and function
● BIOMARKERS
○ Natriuretic peptide levels
TREATMENT
 TREATMENT
● For Acute Congestion:
○ Stepwise approach -->Oxygen, Furosemide IV,Morphine IV as last resort
○ Correct precipitating factors: Arrhythmia, uncontrolled HPN, anemia, pulmonary
infection, thyrotoxicosis, change inappropriate medications, emotional stress
● 1. Diuretics: (For acute CHF, fluid overload or edema)
● Furosemide (Lasix) 20-40 mg IV then maintain on PO later, may double subsequent
doses if no urine output in 20-30 mins (e.g. give Lasix 40 mg IV then 80 mg IV after
30 minutes). If still without urine output, start Lasix drip and consider stat
peritoneal or hemodialysis for resistant cases
● Spironolactone (Aldactone) 25 mg tab OD-TID for CHF class III to IV.
● 2. Vasodilators:
○ Ace-inhibitors: First-line agents for chronic heart failure.
■ Captopril 25 mg 1/2-1 tab q 6-12 hr. Maximum dose of Captopril 50 mg tab TID
■ Enalapril 5-10 mg tab OD-BID, maximum dose of Enalapril 20 mg BID.
Maximize dose of ACE-inhibitors to achieve symptomatic relief of dyspnea. In
patients with contraindication to ACE-inhibitors (e.g. acute renal failure), you
may use Hydralazine 10-25 mg TID and ISDN gsordil) 10-20 mg TID.
○ Angiotensin receptor antagonists:
■ Alternate drug if with ace-inhibitor cough; e.g. Losartan 50 mg 1/2 -1 tab OD
(maximum dose of Losartan 50 mg 1 tab BID).
● Digitalis:
○ Most beneficial in patients with atrial fibrillation. Digoxin 0.25-0.5 mg IV then
complete
loading dose if needed or Digoxin (Lanoxin) 0.25 mg tab BID X 3 days then 1/2 - 1
tab OD thereafter.
● Consider low dose beta-blockers for heart failure.
○ Addition of Carvedilol (Dilatrend) 6.25 mg tab BID. Watch out for hypotension
and CHF within the first 4 hours after intake.
● Other therapeutic options as indicated:
○ Coemyme Q10 10 mg tab TID has some possible benefit.
○ Nitrates: Transderm patch for 1 dose only if with no underlying CAD.
○ ASA 80-160 mg PO OD as indicated.
MANAGEMENT
MANAGEMENT
MANAGEMENT
 MANAGEMENT FOR CKD
● Fluid restriction
○ For patients with congestive heart failure, hypertension, hyponatremia or
excessive weight gain.

● Acidosis:
○ NaHCO3 grain X 1 tab TID
○ aim for bicarbonate level of 24 umol.L for CRF patients.
○ Hyperkalemia

● Hypertension: Treat aggressively

○ Use Ace-inhibitors or Angiotensin II antagonists if without contraindication.

● Hyperphosphatemia:
○ CaCO3 500 mg 1 tab TID to be given at the beginning of meals
○ Maintain serum phosphorus at 4.5-6.0 mg/dl to prevent renal
osteodystrophy
 MANAGEMENT FOR CKD
● Anemia:
○ Correct iron deficiency first. Give PO or IV iron if unable to achieve transferrin
saturation at 25-35 % and Ferritin levels at 200-500 mg/ml.
● Erythropoietin
○ 50-150 units/kg SC 1-3X/week to maintain hematocrit of 32-38.
● Symptomatic Hyperuricemia
○ Give Allopurinol 100 mg 1 tab OD 8. Hypocalcemia: Calcitriol (Rocaltrol) tab or
CaCO3 tab TID

● Vitamins Multivitamins tab OD, Vitamin C sparingly

● Other Options:
○ Ketoanalogues (Ketosteril) 600 mg 1-4 tabs TID

● Adjust all drug dosages according to Glomerular Filtration Rate.

 ETIOLOGY

Valvular Heart Disease (VHD):

Degenerative changes: Age-related degeneration of heart valves (e.g., calcification of
the aortic valve or mitral valve prolapse) is common in older adults.
Rheumatic heart disease: A possible result of untreated or poorly treated streptococcal
infections, which may lead to damage of the heart valves.
Infective endocarditis: Infection of the heart valves could have led to valvular damage.
Congenital heart defects: Abnormalities in valve structure present since birth, though
usually identified earlier in life.
Atherosclerosis: Plaque buildup in blood vessels can contribute to valve dysfunction.

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 ETIOLOGY
Heart Failure (likely caused by VHD and AFib):
Valvular insufficiency or stenosis: The inability of valves to close or open properly can lead to reduced
cardiac output and heart failure.
AFib: The irregular rhythm can exacerbate heart failure by reducing the efficiency of the heart’s
pumping action.
Hypertension: Chronic high blood pressure can lead to heart failure through increased workload on
the heart.

Chronic Kidney Disease (CKD):

Hypertension: Chronic high blood pressure can damage the kidneys over time, leading to CKD.
Diabetes: While not mentioned in the patient's background, diabetes is a common cause of CKD.
Heart failure: Reduced cardiac output can impair kidney perfusion, contributing to kidney damage.
Vascular disease: Atherosclerosis or other blood vessel diseases can reduce kidney function.
 EPIDEMIOLOGY
Valvular Heart Disease (VHD):
Prevalence: Increases with age, affecting 2.5% of the general population,
with higher rates in people over 65 years old.
Risk factors: Aging, hypertension, atherosclerosis, rheumatic fever, and
certain infections (e.g., endocarditis).
Gender: Men and women are equally affected by degenerative valve
disease, though certain conditions (e.g., mitral valve prolapse) are more
common in women.

Heart Failure (Functional Class III):

Prevalence: Heart failure affects about 1–2% of the general population,
increasing to over 10% in those aged 70 and older.
Risk factors: Advanced age, hypertension, VHD, AFib, and ischemic heart
disease are common contributors. CKD further complicates and worsens heart
failure.
Gender: Slightly more common in men, though women are also affected,
especially as they age.

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Chronic Kidney Disease (CKD):
Prevalence: Affects about 15% of the general adult population in the
United States, with higher rates in older adults and those with
diabetes or hypertension.
Risk factors: Hypertension, diabetes, heart failure, and vascular
diseases are common causes of CKD.
Gender: CKD prevalence is slightly higher in women, but men have a
greater risk of progression to end-stage kidney disease (ESKD).
 PATHOPHYSIOLOGY
Pathophysiology of Pulmonary Congestion in VHD, AFib with RVR, and
CKD

1. Valvular Heart Disease (VHD) leads to either pressure or volume

overload in the heart. Mitral stenosis causes increased pressure in
the left atrium, which backs up into the pulmonary circulation,
leading to pulmonary congestion. Aortic stenosis or regurgitation can
also cause left ventricular overload, eventually leading to heart
failure and lung congestion.

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2. Chronic Kidney Disease (CKD) contributes by:
- Volume Overload: Reduced kidney function causes fluid retention, worsening
pulmonary congestion.
- RAAS Activation: Increases blood pressure and fluid retention, stressing the heart.
- Anemia: Reduced oxygen-carrying capacity forces the heart to work harder, further
worsening heart failure.

This combination of conditions creates a cycle of worsening heart failure, pulmonary

congestion, and systemic fluid overload.
THANK YOU PO DOCTOR