28yr male with pain abdomen

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Case presentation:

A 28 yr old male pt was apparently asymptomatic 1month back.He observed that on long standing he developed swelling of both legs which relieved on rest.

12days back he had epigastric pain which was spasmodic type,no aggrevating and relieving factors,for which he had consulted a doctor who gave medications for his pain.

6days back-

As the pain didn't get relieved with medications he consulted another doctor in bhuvangiri who had done ultrasound scan of abdomen.The doctor had given him few medications,but the pain was not reduced.

3days back-

he developed pedal edema along with abdominal distension and facial puffiness

DAY-1-

He presented to casualty with complaints of

 •  epigastric pain  since 12days 

 •  shortness of breath on exertion since 3days

PAST HISTORY-

not a k/c/o DM,HTN,asthma,tb, epilepsy

h/o trauma to the right leg 5yrs back

PERSONAL HISTORY-

Alcoholic since 4yrs -whiskey 60ml/day on every alternate day.

toddy-occassional

no habbits of smoking

family history-

no similar complaints in the family,

O/E-

pt is conscious, coherent and cooperative

no signs of pallor,icterus, cyanosis, clubbing,koilonychia, lymphadenopathy

hypopigmented patches were found on both upperlimbs,trunk and back(seen in family members also)

vitals-

temp-98.6°F

bp-120/80mmhg

pr-118bpm

rr-21cpm

spo2-96 %at room air

CVS-

1.JVP raised up to angle of mandible

2.precordium-

Observer-1:

apex beat at 5th left  intercostal space midclavicular line

Left parasternal heave+ 

thrill-palpable on tricuspid area

S1 S2 heard in all areas,

S1-loud in pulmonary area,pansystolic murmur in tricuspid area

Observer-2:

Inspection: Prominent precordial pulsations 

Palpation: 

Apex: Left fifth to sixth intercostal space just outside the MCL 

Character: forceful 

Base of heart: prominent palpable sound 

Right parasternal heave prominent with very prominent epigastric lift 

Auscultation: 

Apex: S1 normal with soft midsystolic murmur 

Soft midsystolic murmur more prominent at neoaortic area with normal S1. 

Very loud P2 at base with prominent S2 split which is wide but mobile and not fixed. 

RESP-BAE+

P/A-soft, tenderness in epigastric region

CNS-NFND

investigations ordered-

RBS-84MG/DL

treatment given-

1.inj.MONOCEF 1gm/iv/BD

2.inj.PANTOP 40mg/iv/BD

3.inj.LASIX 40mg/iv/TID 

4.inj.TRAMADOL 1amp sos

5.fluid restriction<1lit/day

6.salt restriction<2g/day

DAY 2-

C/O one episode of PND last night,not associated with dry cough

pedal edema +,no signs of dehydration

I/O-800/1400ml

Urology referral notes-

dermatology referral notes-

on woodlamp examination-

O/E-

Pt is C/C/C ,

afebrile,

bp-120/60mmhg,

pr-110bpm, regular rhythm,normal volume

CVS-

precordial bulge +

apex beat at 5th left ics in midclavicular line

parasternal heave+

thrill palpable

S1,S2 heard -loud S1

p/a-soft, tenderness in epigastric region

CNS-NFND

investigations-

2decho-

treatment given-

1.INJ.LASIX 40MG/IV/TID

2.T.SILDENAFIL 5MG OD

3.INJ.PANTOP 40MG/IV/OD

4.INJ.MONOCEF1GM/IV/BD

5.propped up position

6.fluid restriction<1lit/day

7.salt restriction<2g/day

provisional diagnosis-

HEART FAILURE WITH PRESERVED EJECTION FRACTION (60%)  WITH MODERATE PAH WITH LEFT HYDRONEPHROSIS AND PYELONEPHRITIS

Final diagnosis-

HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY