Reginald Chives Case Presentation 2

CASE PRESENTATION
REGINALD CHIVONIVONI
MBBS V
Demographics
Name: HM
Age: 56
Sex: Female
Residence: Blantyre
Referral: Ameka H/c Lunzu rd
DOA: 5/03/24
DOC: 6/03/24
Background
• Known HTN pxt that complicated to Congestive C88ardiac Failure,

(2016), HIV –ve. Good blood pressure control.
• Mastectomy done 2° Breast cancer got treatment x 8/12 (2016)
• Issues of SOB, cough and swelling of feet started in December,
2023
• Admitted last discharged on 2ND February 2024 (5day admission)
on medication however did not take medication, out of stock, no
medication until 2 weeks prior to presentation.
• Now presenting with issues of worsening of symptoms
Presenting Complaint
• Cough x 1/12
• Generalized body swelling x 1/12
History of presenting complaint
Cough x 1/12
• Persistent dry cough sometimes productive,
• Non bloody, white sputum
• <1 tablespoon per day
• Associated with SOB, worsens on walking on flat round, MMRC 3, NYHA III
• Associated with swelling of breast, right upper limb and both lower limbs
• +PND , +orthopnea
• +palpitations, irregular, no known triggers and non specific timing
• No chest pain
• No diurnal variation
• No obvious triggers
• No fevers, no weight loss, no night sweats
Generalized body swelling x 1/12
• Swelling did not completely resolve following previous visit
• Generalized swelling:
• Both lower limbs below & above the knees, abdominal swelling
• Right arm Including hand & left breast
• Not associated with any localized colour changes nor pain
• Associated with 2cm ulcers on medial aspect of ankles that were painless
• Breast produced clear fluid from nipple when expressed
Drug history
• Furosemide 40mg PO BD x 1/12
• Spironolactone 25mg PO OD x1/12
• Atenolol 50mg PO OD x1/12
• Losartan 50mg PO OD x1/12
Allergies
• Nil drug/food allergies
Past Medical & Surgical history
• As in the background
• No history of Diabetes mellitus, asthma or epilepsy
• No previous Tuberculosis diagnosis
Social history
• Divorced and stays with 4 children (youngest 25)
• Gets help from children, funds
• Works as a cook at a secondary school, since 2009, uses fire to cook
• Eats 3 meals a day : porridge, nsima, fish, goat, vegetables, potatoes,
chicken
• Lives in a 3 bedroomed, iron roofed house, gets water from a
borehole
• No history of Smoking, no alcohol
• No history TB contacts
Family history
• No history of Diabetes mellitus, hypertension, asthma or epilepsy
Review of other systems
Neuro Genitourinary
• No headaches • Normal urine
• No dizziness • Non bloody
• No seizures • No dysuria
• No visual disturbances • No nocturia
• No neck stiffness • No urgency
• No increased frequency
Review of other systems
Gastrointestinal Integumentary
• No dysphagia • Painless ulcers on ankles <2cm
• No diarrhea • No rashes
• No constipation
• No weight loss
• No change in appetite
• Normal stools non bloody
• Non foul smelling stools
General examination
• Alert, GCS of 15/15, coughing • No signs of RDS
while seated in bed • No oral Kaposi sarcoma lesions
• Pink cannula left wrist • Warm extremities CRT<3s
• Mildly pale • No gibbous
• Generalized edema • No jaundice
• No cyanosis
• No oral thrush
• No finger clubbing
Vital signs
Parameter DOA DOC
Respiratory rate 18 breaths/min 24 breaths/min
Oxygen saturation 98% ra 94% ra
Pulse rate 84 beats/min 88 beats/min
Blood pressure 124/89 mmHg 122/89 mmHg
Temperature 35.2° C 34.4° C

Respiratory examination
• No obvious chest deformities, scar mastectomy Right breast
• No tar staining, no peripheral cyanosis, no asterixis, No central
cyanosis
• No tracheal deviation, No raised JVP
• Symmetrical chest expansion
• Stony dull percussion note ant & post Right lower lung zones
• Reduced breath sounds ant & post Right lower lung zones
• Reduced vocal resonance ant & post Right lower lung zones
• No crackles in lung bases
Cardiovascular examination
• Distended neck veins, no raised JVP, no central cyanosis, no high arched
palate
• No splinter hemorrhages, no osler nodes, no janeway lesions,
• Warm peripheries, CRT<3sec, No radial- radial delay, no collapsing pulse
• Apex beat 6th intercostal space, left anterior axillary line
• Sacral edema
• No heaves or thrills, no carotid bruits
• Normal heart sounds S1+S2 no added heart sounds
• Bilateral pitting edema above & below the knees
Breast Examination
• Left breast fullness, no discolouration, no peau d’orange, nipple
discharge-clear fluid, no scars, no ulcerations
• Non tender, no masses/lumps, no axillary lymph nodes
Gastrointestinal examination
• Mildly distended, soft, no obvious masses, no distended abdominal
veins, normal inverted umbilicus,
• No tenderness
• No hepatosplenomegaly , -ve palpable masses
• Tympanic all regions, -ve shifting dullness
• No renal angle tenderness
• Normal bowel sounds, -ve renal bruits, -ve aortic bruits
Neurological examination
•Normal gait, no tremors, fasciculations or asymmetry
Cranial Nerve exam
Upper and lower limb examination
Lower limbs Upper limbs
Tone Normal Normal
Power 5/5 5/5
Reflexes Normal Normal
Sensation Crude touch, fine touch, Crude touch, fine touch,

temperature, vibration and pain temperature, vibration and pain
sensations present sensations present
Coordination Heel to shin intact Finger to nose intact
Babinski -ve
Summary
• HM 56y/o F, HIV –ve known HTN pxt that complicated to congestive
cardiac failure 2016. Mastectomy Right breast dx breast cancer,
unable to take all prescribed medication after last hospital admission.
Cough & generalized body swelling x 1/12 associated with SOB.
• O/E distended neck veins, scar from mastectomy Right breast,
displaced apex beat, stony dull percussion note , reduced vocal
resonance & reduced breath sounds RLLZ ant & post, anasarca,
painless ulcers on ankles.
Problem list
Subjective Objective
• Not taking medication
Persistent cough • Distended neck veins
SOB • Displaced apex beat
Generalized body swelling • Stony dull percussion ant&post RLLZ
• Decreased breath sounds ant&post
RLLZ
• Sacral edema
• Nipple discharge
• Mildly distended abdomen
• Painless ulcers on ankles
Differential diagnosis
1. Decompensated Heart Failure 2° :
• Medication unavailability
• Tuberculosis (Mycobacterium tuberculosis)
• Community acquired pneumonia (Streptococcus pneumoniae,
Haemophilus influenzae, Mycoplasma pneumoniae)
• Malignancy(Metastasis to lung)
Investigations
• FBC • Chest X-ray
• U&E • Echocardiogram
• Creatinine • Breast USS
• Sputum Xpert MTB Rif • Abdominal USS
• ECG
• CT chest
• CT abdomen
• Diagnostic/ Therapeutic
pleurocentesis
Results
Measure Result
WBC 7.18 x 10^3

NEUTROPHILS 3.72 x 10^3
LYMPHOCYTES 2.68 x 10^3
RBC 4.62 x 10^6
HGB 12.6g/dL
MCV 84.4 fL
PLT 280 x 10^3/µL
Urea + Creatinine
Measure Result
Urea 158.7 mg/dl
Cr Not done
Chest Xray
ECG
ECHOCARDIOGRAM
29/12/2023 6/03/2024
• Dilated LV & LA • Dilated cardiac chambers
• Limited movement of MV + mild • Thickened mitral valve leaflets
regurgitation
• Poor cardiac contractility
• With regurgitation
• RV & RA normal • Bilateral pleural effusion
• Normal A-valve T-valve P-valve • Mild pericardial effusion
• No Pericardial Effusion • Ejection fraction=44% IVS=1.6cm
• Normal IVS • Impression= Mitral valve stenosis
• Reduced EF= 36-40%
Initial Management
• Furosemide 80mg PO BD
• Spironolactone 25mg PO OD
• Losartan 50mg PO OD
Follow up 10/03/2024
• @0000hrs complaints of SOB • 12 Noon
• O2 sats= 60% ra • Tilted bed 45°, tolerance off O2
• O2 therapy commenced therapy ?
• Nasal Prongs 5litres/min • O2 sats= 94% ra HR= 89bpm
BP=125/86 T=35.6°C
• @0600hrs
• O2 sats=96% on O2
Advised to keep bed tilted
• PR= 90bpm Call for help if SOB occurs
• Temp=34.4°C Continue management
• BP= 133/91mmHg
Current Management
• Furosemide 80mg IV BD
• Ceftriaxone 2g IV OD
• Atenolol 25mg PO OD
• Losartan 50mg PO OD
• Morphine 5mg PO 4hrly
• Bisacodyl 10mg PO nocte
• Review Nephrology team
Follow up 13/03/2024
• @0730hrs Pleurocentesis done = 600ml yellow fluid
• Collected samples for :
1. Xpert MTB Rif
2. Biochemistry (glucose, LDH,
3. Culture and sensitivity
4. WCC & Differentials
• Advised to reduce fluid 1-2L/d and reduce salt intake and do daily
weight checks
Learning Points
1. Sitting up the patient can improve their symptoms of SOB
2. Morphine is a venodilator, can help reduce venous pressure in the
lungs helping with the symptoms of SOB
An Audit of Heart Failure management
among ambulatory adult patients at
QECH, Malawi
E. Mwabutwa, S.Kateta, L.Kinley, T.Ulemu, P.Goodson, A.Muula, J.Kumwenda (2022)
• The study evaluated the management of heart failure among adult patients at Queen
Elizabeth Central Hospital in Malawi.
• Most patients were on at least one neurohormonal antagonist, but only a small
proportion were on the recommended heart failure medication combinations and
doses.
• For example, only 52% of patients were on beta blockers, compared to 66.5% in other
African countries. Additionally, only 14% of patients on enalapril had their medication
up-titrated from the last visit, despite being on suboptimal doses. The study also found
that half of the patients were at risk of hospitalization due to poor adherence to
medications.
• These findings highlight the need for improved adherence to treatment guidelines and
better access to diagnostic tests in the management of heart failure in Malawi.
References
• https://www.mmj.mw/?p=12531
• AMBOSS
• Oxford Handbook of Clinical Medicine (p134-137)
• The Clinical Book 3rd Edition (p347-348)
THANK YOU

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CASE PRESENTATION

• Known HTN pxt that complicated to Congestive C88ardiac Failure,

Respiratory rate 18 breaths/min 24 breaths/min

Oxygen saturation 98% ra 94% ra

Pulse rate 84 beats/min 88 beats/min

Blood pressure 124/89 mmHg 122/89 mmHg

Temperature 35.2° C 34.4° C

Tone Normal Normal

Power 5/5 5/5

Reflexes Normal Normal

Sensation Crude touch, fine touch, Crude touch, fine touch,

WBC 7.18 x 10^3

Urea 158.7 mg/dl

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