55 year old male with chronic heart failure

 

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Case seen by Unit 5 :

Sridevi . M(Intern) 

Sowmya. K ( Intern) 

Mourya ( Intern) 

Shriya ( Intern) 

Dr. Natasha Mam 

Dr. Zain Sir

Dr. Sashikala mam

Dr. Shailesh Patel Sir

Dr. Praveen Naik Sir

Here is a case i have seen:

A 55 year old who is a resident of Narketpally , Nalgonda who is a tailor by occupation came to casualty with complaints of shortness of breath since December 16 which is progressively increasing, pedal edema progressively increasing since 1 month ,abdominal distension since 4 days and decreased urine output since 4 days... 

Patient was apparently asymptomatic/alright 2 months back then he started developed pain in precordial region radiating to left arm,consulted a cardiologist for which angiogram was done which revealed single vessel coronary artery disease( Proximal LAD )..Patient simultaneously had grade 2 dyspnea  which progressed to grade 4 in span of 2 months according to NYHA classification which is associated with orthopnea and paroxysmal nocturnal dyspnea. 

 No complaints of palpitations, chest pain, giddiness

patient observed bilateral pedal edema since 1 month 

Complaints of abdominal distension since 4 days, pain abdomen ( diffuse type) non radiating not associated with vomitings, nausea
Complaints of decreased urine output since. 4 days. 

No complaints of fever, burning micturition, bowel abnormalities. 

Past medical history: known case of diabetes since 4 years and on tablet metformin 500 mg
No past history of HTN, CAD, Asthma, tuberculosis. 
No past history of exposure to chemo radiation, blood transfusion

Past surgical history: 
History of splenectomy done in 2017 in view of splenic abscess 
History of hernia surgery done 2018
History of Angiogram done on 16 th dec 2020
. 


Personal history: His diet is mixed, appetite is normal, bowel movement s regular, decreased urine output, Known case of alcoholic since 30 years 90 ml per day
No known allergies 
No significant  family history

On examination :

General examination: No pallor , icterus,cyanosis, clubbing, generalised lymphedenopathy

Pedal edema upto knee present, putting type, JVP elevated. 

Vitals:

Bp:110/ 70 mm hg

PR:84 bpm

Rr:42 cpm

Cvs examination:

Apex beat at 6 th left intercoastal space lateral to mid clavicular line present 

Muffled S1 and S2 

Respiratory system examination:

Decreased breath sounds in bilateral inter scapular area

Per abdominal examination: per abd distended

No tenderness, no organomegaly

 

Abdominal distension:

Pedal edema. 

Investigations:

Chest X ray 

2 D echo

USG 

Complete blood picture

Renal function tests

Liver function tests

Fbs

HbA1c

2 D echo

Investigation s Day 2:

Diagnosis: Chronic Heart failure with reduced ejection fraction with CKD 

Treatment:

1) Inj. Lasix 80 mg/iv/ BD

2) T. Cardivas 3.125 mg / bd

3) T. Ramipril 2.5 mg /po/ od

4) Inj. Human mixtard insulin 6 nd 4 Units

5) fluid restriction less than 1 l/ day

6) salt restriction less than 2 g/ day

7) bp, pr, spo2 monitoring

8) grbs monitoring 6 th hourly

9) T. Alpha D3 /Od

10) T. Shelcal  /0d

11) Nephro opinion

On starting the patient on Cardivas, ( Carvedilol) we noticed fluctuations in liver enzymes levels .i.e.Elevated liver enzymes levels. 

So we came across articles and case studies showing deranged lft and hepatotoxicity associated with carvedilol