CASE PRESENTATION. By: Sarah Khalil Zeina Shamil Supervised By: DR.ABDULHAK AL_NUAIMI

Transcription

1 CASE PRESENTATION By: Sarah Khalil Zeina Shamil Supervised By: DR.ABDULHAK AL_NUAIMI

2 Name :Manal A. AGE : 22 years Marital status : married Occupation : housewife حي العامل Mosul Residence : DOA : 10 th, Jan, 2013 DOE : 16 th, Jan, 2013

3 Chief complaint and its duration : Shortness of breath 15 days before admission HISTORY OF PRESENT ILNESS : Young lady presented with SOB for 15 days with previous Hx of same complaint before 10 months when she was pregnant in her 9 th month of pregnancy when she started to develop SOB at moderate exertion, orthopnea, generalized body swelling and increase in body wt.. after delivery SOB persist, she admitted to hospital before one month for the same complaint and she received treatment.

4 Now presented with severe SOB of gradual onset which became at rest, and she also developed bilateral leg swelling and abdominal distension which gradually increase in the last 2 weeks, with orthopnea, PND,and palpitation,no cyanosis, no syncopal attack. She had dry cough, no hemoptysis, with sharp chest pain in the Rt lower area which increase by cough, She also had high fever intermittent associated with sweating respond to antipyretic.

5 Review of other systems : GIT : good appetite,no nausea, no vomiting, normal bowel motion, no abdominal pain. GUS : urine slight yellow in color, polyuria,nocturia no dysuria. CNS : headache, dizziness,no LOC, no abnormal body movement. Musculoskeletal : no joint pain, no joint swelling. Skin : no rash

6 Past medical history : Previous hospitalization for same complaint before 1 month. Past surgical history : - ve Drug history and allergy : diuretic and no allergy to drugs Past obstetric history : She is married since 2010, her 1 st pregnancy since 2.5 years, it was normal uneventful pregnancy ended by NVD of male fetus.

7 Family history : No Hx of same condition, no Hx of DM, HT, IHD but there is +ve family Hx of asthma. Social history : Medium socioeconomic state, married has 2 child, non smoker, non alcoholic.

8 EXAMINATION : GENERAL EXAMINATION : young lady sitting on bed conscious, alert looking ill, she was pale, not jaundiced, not cyanosed, dyspneic, tachypnic, good body built. No clubbing, no fine nor flapping tremor with canula on dorsum of left hand with bilateral pitting leg edema

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10 VITAL SIGNS : Pulse rate : 85 beats /min regular, good volume, no special character, condition of vessel wall just palpable. RES rate : 22 breaths / min T : 36.8 C BP : 130 / 80 mmhg

11 Systematic examination: CVS EXAMINATION : By inspection chest shape is normal no deformity, no scar, there is no visible pulsation On palpation apex beat is palpable in 6 th ICS lateral to mid clavicular line, it is thrusting in nature. No thrill, no left parasternal heave. On auscultation loud S1 and S2 with S3 (gallop rhythm) JVP is elevated 7 cm above the sternal angle

12 RES EXAMINATION : Inspection : normal shape of chest Palpation : trachea is central, symmetrical expansion of the chest Percussion is resonant Auscultation : vesicular breathing in all chest with good air entry but reduced in right lower zone, with bilateral basal fine end inspiratory crepitation

13 abdominal examination : Abdomen is distended with fullness in the flanks, move with respiration, umbilicus is central inverted with whitish straia in lower abdomen with evidence of abdominal wall edema. Palpation : abdomen is tense, no mass, no tenderness shifting dullness and transmitted thrill is positive No organomegally

14 Neurological examination : All cranial nerves are normal, normal motor and sensory systems Muskeletoskeletal system : No joint swelling, no deformity, no deformity, normal range of movement

15 Investigation : Chest X ray PA view of the chest It shows gross cardiomegaly, fissural edema in the right side with non homogenous opacity in right lower zone

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17 ECHO: It shows dilated Lt ventricle, Rt ventricle, Lt atrium. EF = 25% Pericardial effusion 3-4 mm

18 US of abdomen : It shows normal liver, gallbladder, kidney, and urinary bladder.

19 Serum sodium = 134 mmol/l Serum potassium = 3.2 mmol/l

20 CBC: It shows hyopochromic microcytic anemia

21 GUE:

22 Diagnosis: peripartum cardiomyopathy

23 Peripartum Cardiomyopathy It is a cardiac dilatation & CHF which may develop during the last trimester of pregnancy or within 6 months of delivery & it is uncommon disorder during pregnancy

24 Etiology: The cause is unknown, although inflammatory myocarditis, immune activation & gestational hypertension have all been incriminated. The patient who develops peripartum cardiomyopathy typically is multiparous, of African ancestry & older than 30 years of age.

25 Clinical features : Symptoms: Fatigue, sob, orthopnea, PND, cheyne-stokes respiration, symptoms of acute pulmonary edema Although vague chest pain may present, syncope due to arrhythmias & systemic embolism may occur Also gastrointestinal symptoms may present like anorexia, nausea, Early satiety & abdominal pain which may be in the right upper quadrant due to liver congestion & abdominal fullness Cerebral symptoms such as confusion, mood &sleep disturbance Nocturia

26 Physical examination General,Tachycardia, labored breathing, cyanosis, bilateral leg edema the pulse pressure is narrow & JVP is elevated, Chest examination will reveal pulmonary crackles, pleural effusion Cardiac cardiomegaly, third & fourth heart sounds are common, mitral or tricuspid regurgitation may occur Abdomen tender hepatomegaly, ascites, jaundice due to liver impairment

27 Investigations: Routine lab testing CBC, Serum electrolytes, RFTs, LFTs Chest X-ray: To know the size of the heart, the lungs state which may show evidence of pulmonary HT, interstitial edema & or pulmonary edema ECG : Shows sinus tachycardia or AF, ventricular arrhythmias Lt atrial abnormality, low voltage, diffuse non specific ST-segment &T-wave abnormalities, sometimes intraventricular & or AV conduction defect

28 Echocardiography: Lt ventricular dilatation & dysfunction Cardiac catheterization: Lt ventricular dilatation & dysfunction,elevated LT & often Rt sided filling pressure & diminished cardiac output Other Investigations Chest roentgenogram Radionuclide studies

29 Treatment: hydralazine and nitrates are the drugs of choice during pregnancy After delivery: Diuretics ACE-I Angiotensin receptor blockers B-blocker

30 Additional therapy Vasodilators Spironolactone Digoxin But the definitive treatment is cardiac transplantation

31 Prognosis: It is related to whether the heart size is return to normal after the first episode of CHF, if it does, subsequent pregnancies may sometimes be tolerated, bit it associated with an increased risk oh recurrent CHF, but if the heart remains enlarged & / or LV EF Remains depressed after 6 months the prognosis is poor & the patient should be encouraged to avoid further pregnancies

32 Reference : Harrison s principles of internal medicine 17 th edition Davidson s principle & practice of medicine 20 th edition

33 Thank You