Summary 14

Mr MM, 63 year old Malay man, with underlying hypertension, congestive cardiac failure and history ischemic heart disease presented with shortness of breath 2 days prior to admission which was associated with reduced effort tolerance. He also complained of fatigue, orthopnea, paroxysmal nocturnal dyspnea and bilateral lower limb swelling. He was under follow up for his medical condition and is complaint to the medications (perindopril, simvastatin, acetylsalicylate acid, furosemide and trimetazidine). However, he was non-compliant to the fluid restriction and drank about 2L of water per day.

Question: What is the reason for drinking so much water? Based on his urine output and the ambient temperature, how much of his intake is being retained?

There were multiple hospital admissions since June 2017 for the same reasons which were shortness of breath and leg swelling.

Question: Are all these admissions because of his excessive fluid intake?

He also follows up at Hospital Sultanah Aminah, Johor Bahru and is planned to have coronary revascularization at end of September. Patient does not smoke or consume alcoholic drink.

Question: Is it possible that his chronic congestive cardiac failure is related to persistent myocardial ischemia?

On examination, vital signs were normal (BP 103/60mmHg, pulse 88bpm, respiratory rate 20 breath/min, temperature 37°c). There was no pallor or cyanosis. There was bilateral pedal edema up till mid shin. On cardiovascular examination, his JVP was raised to 4cm.

Question: Why do you consider a JVP of 4cm to be "raised"?

Apex beat was deviated to 6th ICS, 3cm lateral to mid-clavicular line. S1 and S2 were heard. There was no murmur or additional heart sound. There was bibasal fine crepitation. Other examinations were normal.

Full blood count was normal. Renal profile revealed hypokalemia.

Question: What is the reason for his hypokalemia?

ECG showed poor progression of R wave, left axis deviation and left ventricular hypertrophy.

Question: What is the reason for these changes seen in the ECG?

Chest radiograph revealed cardiomegaly. ECHO showed ejection fraction of 40%. Patient was diagnosed as acute decompensated cardiac failure secondary to non-compliance to fluid restriction. He was given IV furosemide 40mg stat and TDS and IV 1g KCL. Other previous medications were continued. He responded well to the treatment and the shortness of breath and leg swelling improved.

Question: What do you understand from the fact that he improved with IV frusemide?

Patient was discharged on the second day of admission. He was on 500mL fluid restriction. An appointment at medical outpatient appointment was scheduled in 3 month time. Patient will also continue the cardiology follow up in Hospital Sultanah Aminah. Johor Bahru

Question: What is the value in telling the patient something that he is unable to obey ("500mL fluid restriction")? What medicine do you think should be considered at this point?

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