FACULTY OF MEDICINE

MEDICINE POSTING
YEAR 3 2014
CASE WRITE-UP 2

NAME :

MATRIX NO :

NB: IF FOUND,: PLEASE KINDLY RETURN TO DEANS OFFICE OF UITM SG BULOH

ROTATION

GROUP :

SUPERVISOR :
NB: IF FOUND, PLEASE KINDLY RETURN TO DEANS OFFICE OF UITM SG BULOH

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Presenting Ilness:

Mr. S, a 48 year old Malay gentleman with underlying hypertension and diabetes
mellitus presented to Emergency department of Hospital Sungai Buloh with a
complaint of shortness of breath and bilateral leg swelling since July 2014.

History of Presenting Ilness:

He was previously admitted to Hospital Sungai Buloh with the same presentation
for 3 times. The shortness of breath occurs for about 20 minutes and relieved by
rest. The bilateral leg swelling is up to thigh associated with numbness. He also
complaint of reduced effort tolerance as he can no longer climb up stairs for 1-2
floors, and can only walk less than 100 meters as he is getting tired easily and
shortness of breath.

He did also complaint of chest pain which is localized on the left side of chest
wall, which is sudden in onset, non-radiating, triggered by exertion, lasting for
about 30 minutes and the pain score of 5 was given by the patient by taking 0 is
no pain and 10 is the most painful sensation. He also complaint of dizziness that
lasts for about 5 minutes. However, he denied of any syncope. He is taking 2
tablets of Panadol to relieve the chest pain and dizziness.

He also complaint that he has to sleep with 2 pillows, as he will have shortness of
breath when lying supine and he also complaint paroxysmal nocturnal dyspnea.
Other associated symptoms are sweating, palpitations, nocturia, polyuria,
polydipsia, diarrhoea 10 times a day which is loose watery stool and no black
tarry stool, vomiting 10 times a day with food contents and no hematemesis with
generalized abdominal pain with a fever associated with chills and rigors and
history of taking food outside, loss of appetite and loss of weight.

Otherwise there is no other significant findings,

Systems
General
Cardiovascular System
Respiratory System
Central Nervous System
Gastrointestinal System
Urinary System
Findings
There is no general pain elsewhere.
No cyanosis, No syncope or presyncopal
attack
No cough, No hemoptysis
No headache, No confusion
No nausea
No dysuria, No urinary and bowel
incontinence

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Musculoskeletal System No stiffness of joints
Endocrine System No hoarseness of voice, No heat or cold
intolerance
Skin No rashes

Past medical history

He has underlying diabetes mellitus and hypertension for the past 10 years and
not compliance to medication and under Klinik Kesihatan Sungai Buloh follow-up.
He also has hepatitis B since July 2014. He had one surgery done at Hospital
Sungai Buloh in 2012 for carbuncle drainage on his back. He had also a history of
pulmonary tuberculosis 20 years ago and he managed to complete the
treatment. He had no allergies to drugs and foods.

Family History

His mother is having diabetes mellitus while his father had hypertension,
however his father died at the age of 60 because of old age. Otherwise, all family
members were healthy.

Social History

He is an ex-smoker whose smoke 1 pack of cigarettes per day for 20 years. He is

not taking any elicit drugs. He is not taking any alcohol. He is a security guard
working at one of the bank in Kota Damansara. He is currently live with his wife
and children at Kepong.

Physical Examination

He was lying comfortably in a supine position with a bed prop-up to 45 degrees.

He does not look ill. He is alert for time, place and person. He is not in pain or in
respiratory distresses and his hydration status was adequate by evidence of no
sunken eyes and dry lips. There are no muscle wasting, no gross deformity and
no abnormal movements. There is a branula inserted on his right wrist.

Vital Signs

Temperature: Afebrile

Blood pressure: 169/95 mmHg

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Pulse rate: 98 beats per minute

Respiratory rate: 20 breaths per minute

SPO2: 96% under room air

Interpretation: He is hypertensive. Otherwise, all the parameters were

normal.

Hands

His palm was warm, moist and pink. Capillary refill time is less than 2
seconds.
No palmar erythema.
No peripheral cyanosis.
There are no nail abnormalities such as nail clubbing, leukonychia and
koilonychia.
There are no stigmata of infective endocarditis such as Oslers node,
Janeway lesion, splinter hemorrhages.
No flapping tremor present.

Eyes

There is mild conjunctiva pallor.

No scleral jaundice.
No stigmata of dyslipidemia such as xanthelasma and corneal arcus.

Mouth

Buccal mucosa was moist and no coated tongue indicating good

hydrational status.
No central cyanosis noted.

Face and Neck

No dysmorphic facies noted.

The lymph node was not palpable.

Legs

His feet was warm and dry.

There is bilateral pitting oedama up to knee level.

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 Scaling of the skin probably due to shrinkage of the oedema following
diuretics.

Interpretation: He has mild conjunctival pallor suggesting anemia and

bilateral pitting oedema up to knee level, all other findings were
normal.

Systemic Examination

Cardiovascular System Examination

1. Inspection:
The jugular venous pulse is not raised. The chest wall moves
symmetrically with each respiration. There is no chest wall deformity, no
surgical scars, no dilated veins, no skin discolouration, no visible pulsation
of the apex beat noted.
2. Palpation:
The apex beat is at left 5th intercostal space and mid-clavicular line, and
there is no heaves or thrills were palpable
3. Percussion:
Normal cardiac dullness.
4. Auscultation:
Normal heart sound S1 and S2 heard, no added sounds or murmurs.

Interpretation: There was no abnormalities detected.

Respiratory System Examination

1. Inspection:
There was no chest wall deformity such as pectus excavatum or pectus
carinatum. Chest wall moved symmetrically with respiration. There was no
surgical scars, no dilated vein and no visible pulsation. No usage of
accessory muscle noted.
2. Palpation:
Trachea was centrally located. Chest expansion was symmetrical on both
sides of the lungs. Vocal fremitus reduced on right lower zone of the right
lungs but normal on the left lungs.
3. Percussion:
There is loss of resonance on right lower zone of the right lungs but normal
on the left lungs.
4. Auscultation:
Vesicular breath sounds was reduced on right lower zone of the right
lungs. There was no added sounds heard.Vocal resonance is reduced on
the right lower zone of the right lungs.

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Interpretation: There is loss of resonance, reduced air entry, vocal
fremitus and vocal resonance on the right lower zone of the left lungs.

Gastrointestinal System Examination

1. Inspection:
The abdomen is symmetrical, flat and moves with each respiration. The
umbilicus is inverted and centrally located. There are no surgical scars, no
dilated veins, no skin discolouration, no visible peristalsis, no visible
pulsation.
2. Palpation:
The abdomen was soft and non-tender. No abdominal mass detected. The
liver, spleen, and kidney was not palpable. There was no fluid thrills and
shifting dullness noted.
3. Percussion:
The lower border of the liver is at right lower costal margin and upper
border is at 6th intercostal space.
4. Auscultation:
There was normal bowel sounds, no renal bruits heard.

Interpretation: No abnormalities detected.

Summary

A 48 year old Malay gentleman, with underlying hypertension and diabetes

mellitus for 10 years presented to Emergency Department of Hospital Sungai
Buloh with a complaint of bilateral leg swelling and shortness of breath since July
2014 associated with orthopnoea and paroxysmal nocturnal dyspnea and easily
fatigue. The vital signs showed that he is hypertensive and tachypnoeic. On
physical examination, he has mild conjunctival pallor, bilateral pitting oedema up
to knee level, reduced air entry on right lower zone of the lungs, loss of
resonance on percussion, reduced vocal fremitus and resonance on the right
lower zone of the right lungs.Impression would be congestive cardiac failure.

Provisional Diagnosis

Congestive Cardiac Failure

Points to support:

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 He has hypertension for 10 years as hypertension can cause heart failure.
Shortness of breath.
Orthopnea.
Paroxysmal nocturnal dyspnea.
Bilateral pitting oedema up to knee level.

Differential Diagnosis

Chronic Kidney Disease Points to support:

Fatigue
Loss of appetite
Nocturia and polyuria
Bilateral lower limb oedema
Anemia
Uncontrolled diabetes mellitus
Points to against:
No itching
No polyneuropathy
No insomnia
No paraesthesia and tetany
Liver Failure Points to support:
He has Hepatitis B
Raised liver enzymes
Bilateral lower limb oedema
Points to against:
No stigmata of chronic liver disease
No hepatomegaly
Cellulitis Points to support:
Bilateral lower limb oedema
Points to against:
No blister
Afebrile

Investigations

1. Full Blood Count(FBC)

Indication: To measure the levels blood components indicating the presence of

infection or inflammation (White Blood Cells), a state of anaemia (Haemoglobin,
Hematocrit) as this patient has mild conjunctival pallor or coagulopathy (Platlet
Count).
Parameters Results Normal Range
Red blood cell 3.16 X 10^12/L 4.5-6.3 X 10^12/L

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White blood cell 12.09 X 10^9/L 4-11 X 10^9/L
Hemoglobin 7.5 g/dL 12.0 18.0 g/dL
Hematocrit 23.8% 36 56%
Mean cell volume 75.3 f 78-100 fl
Mean cell hemoglobin 23.7 pg 27-32 pg
Mean cell hemoglobin 31.5 g/dL 31-37 g/dL
concentration
Red cell distribution width 16.6% 11.6-14.6%
Platelet 117 X 10^9/L 150-400 X 10^9/L
Percentage of neutrophil 87.1% 40-75%
Percentage of lymphocyte 8.3% 20-45%
Percentage of monocyte 4.5% 2-10%
Percentage of eosinophil 0.0% 1-6%
Percentage of basophil 0.1% 0-1%
Absolute neutrophil 10.54 X 10^9/L 2-7.5 X 10^9/L
Absolute lymphocyte 1.00 X 10^9/L 1.3-3.5 X 10^9/L
Absolute monocyte 0.54 X 10^9/L 0.2-0.8 X 10^9/L
Absolute eosinophil 0.00 X 10^9/L 0.04-0.44 X 10^9/L
Absolute basophil 0.01 X 10^9/L <0.01 X 10^9/L
Mean Platelet Volume 9.2 fL 7.5- 11.5 fL

Interpretation: Low erythrocyte, hemoglobin, and hematocrit might

suggest anemia. Neutrophilia might suggest there is an infection is
going on most likely is bacterial infection. Low in lymphocyte count
might suggest viral infection such as hepatitis. Low in platelets might
suggest any splenomegaly.

2. Liver Function Test (LFT)

Indication: To assess the nutritional status from the albumin level or any liver
damage or to act as a baseline before starting any intervention to the patient.

Parameters Results Normal Range

Total Protein 79.0 g/dL 63 79 g/L
Globulin 55 g/L 19-33 g/L
Total Bilirubin 18.8 umol/L < 17 mol/L
Alanine Transaminase 41 U/L 7 56 U/L
(SGPT)
Albumin 24 g/L 35 50 g/L
Alkaline Phosphatase 241 U/L 30 -120 U/L

Interpretation: There is a rise in globulin level, total bilirubin, albumin

and alkaline phosphatase suggestive of congestive cardiac failure or
any underlying liver problem.

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 3. Renal Function Test

Indication:To assess renal function especially to determine hydration status of

patient, identify any electrolyte imbalance, or any chronic kidney disease as this
patient having hypertension and diabetes mellitus or to act as a baseline before
starting any intervention for this patient.

Parameters Results Normal Range

Urea 15.8 mmol/L 3.0 6.5 mmol/L
Sodium 137 mmol/L 135-145 mmol/L
Potassium 4.40 mmol/L 3.5-5.0 mmol/L
Chloride 103.0 mmol/L 133-145 mmol/L
Creatinine 386.5 umol/L 60 125 mol/L

Interpretation: There is a rise in urea and creatinine suggestive of

kidney damage.

4. Cardiac Markers

Indication:To check for any rise in cardiac enzymes that suggest of myocardial
cell damage.

Parameters Results Normal Range

Aspartate Transaminase 99 U/L 14-20 U/L
Lactate Dehydrogenase 404 U/L 70-250 U/L
Creatine Kinase 1511 U/L 25-195 U/L
Troponin I 0.170 ug/L < 0.1 ug/L

Interpretation: All the cardiac enzymes was elevated indicative of heart

failure and myocardial damage.

5. HbA1c Test

Indication: To check for the level of HbA1c as this patient have Diabetes
Mellitus for the past 10 years and to check whether the patient is compliance or
not to medication for the past 1 month.

Interpretation: HbA1c level for this patient is 5.2 most probably is low
because the hemoglobin concentration in this patient also reduced.

6. Electrocardiogram(ECG)
Indication:To check if there is any electrocardiogram waves changes such as ST
elevation, ST depression, T wave inversion, pathological Q waves.

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Interpretation: Sinus Tachycardia with no ischaemic changes.
7. Chest X-ray

Indication:To check If there is any abnormality of the heart such as

cardiomegaly or any pulmonary problem such as congestion or collapse of the
lungs as there is reduced air entry on lower left zone of the right lungs.

Interpretation:Fibrotic changes over right lower zone, no pleural

effusion seen with fibrotic changes over the left middle zone probably
due to previous pulmonary tuberculosis infection.

8. Echocardiogram

Indication:To assess the function of the heart such as the valve, the chamber
sizes, and the ejection fraction.

Interpretation: Reduced left ventricular systolic function and moderate

left ventricle systolic dysfunction with ejection fraction of 38%.

Final Diagnosis

Congestive Cardiac Failure

Management

General measures
Strict bed rest which is sit up right as the paying is shortness of breath
when lying down supine.
Daily weight monitoring to see how much weight is loss following the
administration of diuretics.
Restriction of fluid 800ml/day
Vital sign monitoring

Input output chart monitoring

Specific measures
Flagyl 400mg TDS
Frusemide 80mg
Bisoprolol 2.5mg
Atorvastatin 40mg
Perindopril 2mg
Aspirin 75mg
Indur SR 60mg
Omeprazole capsule 60mg

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Discharge Summary

Mr. S was discharge on 18/10/2014. He was planned for cardiology referral in

Hospital Serdang 2/12/2014. The current medication still needs to continue
giving to him.

Discussion

Firstly we should understand or discuss a about the cause of heart failure in this
patient. As we know, there are a lot of etiological causes of heart failure.

Among the etiologies of heart failure are:

Infection
Anemia
Thyrotoxicosis
Arrhythmias
Rheumatic, viral and other forms of myocarditis
Infective endocarditis
Physical, dietary, fluid, environmental and emotional excesses
Systemic hypertension
Myocardial infarction or acute coronary disease
Pulmonary embolism

Other causes that may lead to heart failure:

Non- compliance to hypertensive medication

High water intake

Heart failure is described as a state when heart cannot maintain adequate

cardiac output or can do so only at the expense of elevated filling pressures. The
prevalence of the heart failure is usually higher for those ages between 80-89
years old. The prognosis of heart failure due to left ventricular is poor which
approximately 50% within 2 years, because many of them die from ventricular
arrhythmias or MI. This patient has chest pain, but according to a studies showed
that although pain is commonly reported in patients with chronic heart failure, it
seems unlikely that the pain is due to angina, even in patients with underlying
coronary heart disease.

How heart failure occur?

Cardiac output is a function of the preload, the afterload and myocardial

contractility. When cardiac output falls, impaired renal perfusion causes

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stimulation of the renin-angiotensin-aldosterone system, leading to arteriolar
vasoconstriction to increase afterload and salt and water retention. The decrease
in renal perfusion explained the reduce urine output in some patient. Activation
of the sympathetic nervous system also occurs and may initially maintain cardiac
output through an increase in myocardial contractility, heart rate and venous
return. However prolonged stimulation leads to cardiac myocytes apoptosis,
hypertrophy and focal myocardial necrosis which characterized by less
contractility. These changes produce further fall in cardiac output which then
create a vicious cycle of stimulation.

To establish a clinical diagnosis of congestive heart failure by Framingham

criteria, at least we need two major or 1 major with 2 minor criteria to diagnose
someone with congestive cardiac failure.
Major criteria:
Paroxysmal nocturnal dyspnea
Neck vein distention
Rales
Radiographic cardiomegaly (increasing heart size on chest
radiography)
Acute pulmonary edema
S3 gallop
Increased central venous pressure (>16 cm H2O at right atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in response to treatment

Minor criteria:
Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Decrease in vital capacity by one third from maximum recorded
Tachycardia (heart rate>120 beats/min)

The clinical manifestations of heart failure are:

Breathlessness
Orthopnea. This is due to increased venous return to lungs when lying flat.
Paroxysmal nocturnal dyspnea usually occurs due to depression of
respiratory centre and reduced adrenergic stimulation at night.
Fatique and weakness. This is because reduce oxygen perfusion to skeletal
muscle.
Cheyne-Stokes respiration. Also known as periodic respiration or cyclic
respiration. There is apneic phase during the PaCO2 rises and fall in paO2
causing changes in arterial blood composition which then cause
hyperventilation and hypocabnia, which then cause apneic state to come
back.

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 Abdominal symptoms. Anorexia and nausea associated with abdominal
pain and fullness frequent complaints and may be related to congested
liver and portal venous system.
Cerebral symptoms. Occurs when heart failure accompany with cerebral
artherosclerosis which reduce perfusion to the brain then causing
confusion.
Pulmonary rales, crepitant rales and dullness to percussionover the lung
base are common in patients with heart failure because of pulmonary
edema.
Cardiac edema. Frequently occurs in the sacral region of patient who are
bed-ridden and pitting edema of extremities and face.
Hydrothorax and ascites caused by pleural effusion in congestive heart
failure.
Congestive hepatomegaly.
Jaundice is the late finding in heart failure which is associated with
elevations of both direct and indirect bilirubin due to hepatocellular
hypoxia associated with lobular atrophy. Hepatic enzymes are frequently
elevated.
Cardiac cachexia. Severe chronic heart failure cause cardiac cachexia by
cause increase circulating tumour necrosis factor, elevation of metabolic
rate (increase respiratory rate), anorexia, nausea and vomiting due to liver
congestion or digitalis intoxication.
Other manifestations such as cold, pale and diaphoretic extremities
because of reduce blood flow.

From all of the above manifestations, Mr. S manifested shortness of breath, and
reduced effort tolerance. His shortness of breath can be explained by the flow
chart below:

Investigations:

We can investigate heart failure by doing ECG, which may give clues to the
etiology of heart failure such as left ventricle hypertrophy and evidence of

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previous MI. Besides, chest x-ray also can reveal cardiomegaly and shows
characteristics changes in pulmonary edema, such as distension of upper lobe
pulmonary veins (bat wings appearance), Kerley B lines, hazy hilar opacification
and pleural effusion.

Other than that, basic baseline laboratories investigation also important to

identify complication such as reduce renal function or precipitating factor such as
anemia and infection. Echocardiography is also important to assess severity and
to find out what are the causes of the heart failure.

Management:

Management of heart failure patient we can divide it into two types of therapy;
drug therapy and non-drug therapies. For drug therapy, we can give ABCD,
which includes ACE inhibitors, Angiotensin receptor blockers, B-blockers,
Calcium channel blocker (for diastolic heart failure), Digoxin, and vasodilators
while for non-drug we can use cardiac resynchronization therapy, implantation of
cardiac defibrillators, revascularization with coronary artery bypass grafting or
percutaneous coronary intervention, cardiac transplantation and ventricular
assists devices.

Prevention of Heart Failure:

There are many factors that increases the risk of getting a heart failure such as
smoking, hypertension, obesity, dyslipidemia to name a few. Therefore, lifestyle
changes or even by taking medication can reduced the risk of getting a heart
failure.
Stop smoking
Keep blood pressure at a healthy level
Keep the cholesterol level under control
Maintain a healthy weight
Eat healthily by taking food that has low fat content
Exercise regularly

References

1. Kumar PJ, Clark ML. Kumar and Clark's Clinical Medicine. W.B. Saunders
Company; 2012.
2. Longmore M, Wilkinson I, Baldwin A et al. Oxford Handbook of Clinical
Medicine. Oxford University Press; 2014.
3. Kumar V, Abbas AK, Aster JC. Robbins Basic Pathology. Saunders; 2013.
4. Clark AL, Goode KM. Do patients with chronic heart failure have chest
pain?. Int J Cardiol. 2013;167(1):185-9.

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SUPERVISORS COMMENTS ON CASE WRITE UP

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