Case presentation

Leah Zuze
Patient demographics
• Name : S.M
• Age :38 years old
• Sex : Female
• Residence : Chilomoni
• DOA: 26/9/24
• DOC : 1/10/24
• SOH: patient, health passport, patient file
Presenting complaint
• Swelling of lower limbs x 1/12
Background
• Known PLHIV since 2017 on 13A and CPT
• Known patient with congestive cardiac failure
• Was admitted 4 months ago for dry cough, worse on lying down and
fatigue on exertion
• Chest radiograph showed air bronchograms and bilateral
opacifications
• Was treated for community acquired pneumonia, ?cor pulmonale
• Follow up cardiac echo concluded congestive cardiac failure
• Was put on spironolactone and atenolol but had persistent vomiting
so was switched to furosemide
• 2 months ago was admitted again for limb swelling and jaundice
• Was treated for CCF secondary to cor pulmonale with furosemide,
atenolol and spironolactone
• LFTs
• U and Cr
• Hep B was negative
History of presenting complaint
• Since second discharge, the symptoms improved (except jaundice)
• Was well until a month ago when she started having swelling of lower
limbs, both sides, not associated with pain or time of the day
• Associated with a dry cough worse on lying down, and at night, severe
enough to keep her awake at night, sometimes wake up suddenly
coughing
• But no fever, weight loss or night sweats
• A/w fatigue and shortness of breath on exertion- walking a football
ground distance, relieved by rest
HPC continued
• A/w heart palpitations, but no pallor or dizziness
• A/w generalised chest pain exacerbated by coughing, not radiating to
the jaw or inner aspects of arm
• Denied ever smoking or taking alcohol
• No hx of HTN (records), or DM (no records) or increased thirst or
hunger
HPC continued
• The yellowing of eyes was gradual, no hx of use of local herbal
medicine
• No history of blood transfusion
• No abdominal pains
• No vomiting or loose stools
• Deep yellow urine, no painful urination, increased frequency since
furosemide, brown stools?
• No skin itching
Review of other systems
• Neurological system
No headache • Hematological system
No confusion No easy bruising
No convulsion No bleeding on minor injury
Past medical hx
• 2 admissions since June as in HPC
• HIV sero reactive since 2017
• Treated for TB in 2019
• No hx of asthma
Drug history
• Spironolactone 25mg PO OD (o/s)
• Atenolol 25mg PO OD
• Furosemide 40mg PO OD
Adherence?
Family hx
• Positive family hx of hypertension (mother)
• No hx of diabetes mellitus, asthma
• No hx of cancers
• No one else is coughing at home
Social hx
• Divorced in 2017, has had one life sexual partner
• Has 3 children (15, 9, 7)
• A Christian (Seventh Day Baptist), is comfortable with blood
transfusions
• Can afford at least 3 meals in a day
• Used to work in a shop, now resigned due to illness
• HLE form 2
Physical exam
• General impression No conjunctival pallor
Alert GCS 15/15 No glossitis and angular cheilitis
Good nutritional status No palpable
Coughing frequently supraclavicular/axillary lymph
nodes
Subjectively mild respiratoty
No leukonychia
distress
No koilonychia
Jaundiced sclera
No palmar erythema
Edema of legs and feet
No calf tenderness
Vital signs
Parameter on admission On clerking
Respiratory rate Not recorded Add
Oxygen saturation 100% on RA
Pulse rate 129 bpm regular
Blood pressure 109/79mmhg
temperature 36.8℃
Respiratory system
• No nasal flaring, no chest deformities, no recessions or indrawings
• Central trachea, symmetrical chest expansion in all lung zones, Tactile
fremitus
• Normal percussion note in all lung zones bilaterally except some
duller percussion note on the right mid axillary line lower lung zone
• Fine inspiratory crackles in the lower lung zones bilaterally
• Reduced vocal resonance on the right lower zone
Cardiovascular exam
• Warm peripheries, CRT<2S
• Raised JVP (10cm H2O)?
• Normoactive precordium.
• No heave.
• No thrill
• Displaced Apex beat to the 7th ICS AAL
• S1+S2+0?
• No loud P2?
GIT exam
• Flat, soft and nontender
• No hepatosplenomegaly
• No palpable gall bladder, negative murphy’s sign
• No ballotable kidneys
• No masses
• No fluid thrill or shifting dullness
• Normal bowel sounds
• No renal artery or abdominal aortic bruit
 Cranial
NERVE
nerve examination
FINDING
I Intact
II • Normal visual acuity
• Normal accommodation
• Normal visual fields
III,IV,VI • Equal pupil size(3mm) and equally reacting to light
• No nystagmus
• Normal eye movements in all directions
V • No temporalis or masseter muscle wasting
• Normal light touch
VII • Able to make facial expressions
VIII • Hearing and balance intact
IX,X • Uvula centrally located, normally swallowing
XI • Able to shrug shoulders and turn head against resistance

XII • No tongue wasting or deviation

PERIPHERAL NEUROLOGICAL EXAM
LUL LLL RUL RLL
on inspection no tremors, no tremors, no tremors, no tremors,
fasciculations fasciculations fasciculations fasciculations
involuntary involuntary involuntary involuntary
movements or movements or movements or movements or
muscle wasting muscle wasting muscle wasting muscle wasting

power 5/5 5/5 5/5 5/5

tone Normal normal normal normal

reflexes normal normal normal normal

sensation intact intact intact intact

coordination intact intact intact intact

Breast examination
• Symmetrical breast size
• No masses
Summary
• This is a case of S.M, 38 years old female, known CCF patient, HIV
sero R presented with cough, limb swelling and jaundice. O/E she was
in respiratory distress, bilateral basal crackles and signs of right sided
effusion.
Problem list
• Subjective • Objective
Bilateral limb swelling Bilateral basal fine inspiratory
Cough crackles
Fatigue on exertion Signs of right sided perfusion
Nocturnal cough Raised JVP?
Paroxysmal nocturnal dypnoea Bilateral pitting edema
Orthopnea Tachypnea?
Yellowing of eyes Jaundice
Impression

Acute decompensation Hepato- Jaundice

on chronic heart failure cardiac
(CCF) H syndrome
NYHC III
Differential Diagnosis
• Heart failure • Jaundice
1. Dilated cardiomyopathy • Hepatic
2. Cor pulmonale • Cardiorenal syndrome
• Infective hepatitis
Precipitated by
•C
• Failure to take drugs (o/s)
• Tuberculosis?

Superimposed pneumonia
Investigations
• Bloods • Imaging
• Full blood count • Chest radiograph
• Urea and creatinine • Echocardiogram
• Liver function tests • CT Pulmonary Angiography
• BNP • Abdominal USS
• CD4 count • FASH
• Others
• ECG
• Urine LAM
FBC results
Parameter result Normal ranges
WBC 7.9 x103 µL 3.39-8.86
RBC 4.89x 106 µL 3.91-5.31
HGB 11.5g/dl 11.1-14.7
MCV 67.3- fL 71-95
PLT 152 x 103 µL 150-450
NEUT 46.3% 40.2-71.4
LYMPH 45.5% 21.6-49
Urea and creatinine
• Urea :
• Creatinine:
Liver Function Tests
CD4 Count
• 1075
Erect Chest Radiograph
Cardiac echo
• LV: Dilated LV with all over impared function EF 14%
• RV: Dilated RV, impared function, lapse 1.3cm RV 5’6cm/s
• LA + RA enalarged
• AV: 3 cups normal PV normal mild PR
• MV: Moderate MR reduced filling long vene
• TV: Severe TR with systolic neverdal levera vene
• UL: Dilated without collapse
• Mild pericardial effusion
• Impression Dilated cardiomyopathy
• Liver failure
Urine Dipstick
• Uro Negative
• Glucose 100(5.5)
• Bil +
• Ket +
• SG 1.030
• Blood ++50
• pH 6
• Pro ++
• Nitrites Neg
• Leu Neg
• Ascorbic acid Neg
Working diagnosis
• CCF secondary to cor pulmonale
Management
• Admision to 4A • Causative pathology
• Ceftriaxone 2g IV OD • Pulmonary hypertension-
palliative care
• Symptomatic relief
• Furosemide 80mg IV BD
• Spironolactone 25mg PO OD
• Atenolol 25mg PO OD