Summary 5

Mr. LHW, a 66 years old Chinese gentleman, with underlying congestive cardiac failure, diabetes mellitus, hypertension and ischemic heart disease presented with shortness of breath and cough for 2 weeks and bilateral pedal edema for 1 week duration. His shortness of breath worsened by exertion and was associated with wheezing. He also had chesty cough with whitish sputum which was progressively worsened. He then sought treatment in clinic and was diagnosed with pneumonia.

Question: What do you think was the evidence on which the diagnosis of pneumonia was made?

He also had orthopnea, occasional paroxysmal nocturnal dyspnea and fever since the onset of his breathlessness.

Question: What do these symptoms of "orthopnea, occasional paroxysmal nocturnal dyspnea" suggest to you?

His bilateral edema started one week later and extended up to his knee region. He also complained of reduced effort tolerance (NYHA II). He sought treatment on day 5 of illness and was treated with tablet erythromycin and tablet chlorpheniramine, in which his fever resolved but other symptoms persists.

Question: Why was he given chlorpheniramine, which is an antihistamine?

On physical examination, there was displaced apex beat at 6th intercostal space and 2 cm lateral to mid-clavicular line, raised jugular venous pressure of 6 cm, ascites, bilateral pedal edema up to the knee and bilateral basal crepitation on auscultation of the lungs.

Question: What does this finding of "displaced apex beat at 6th intercostal space and 2 cm lateral to mid-clavicular line" suggest to you? What is wrong with this statement: "raised jugular venous pressure of 6 cm"?

Full blood count and renal profile were normal. Chest X-ray revealed cardiomegaly, cephalization of pulmonary vessels and right lower zone consolidation.

Question: What makes an opacity in the lungs on chest x-ray suggestive of consolidation?

Arterial blood gas showed metabolic acidosis with respiratory alkalosis.

Question: Explain why he has metabolic acidosis and why he has respiratory alkalosis

His ECG showed sinus rhythm without ischemic changes and troponin I was normal. His random blood sugar was also being monitored in the ward as his metformin was withheld.

Question: Why was the metformin withheld?

He was treated as decompensated congestive cardiac failure secondary to community-acquired pneumonia.

Question: Is the CAP the cause of his cardiac failure or is it merely the precipitating cause?

In the ward, he was given intravenous furosemide 40 mg TDS, tablet bromhexine 8 mg TD, intravenous ceftriaxone 2 g STAT and 1 g OD for 3 days. He was also put on restriction of fluid of 500 cc per day.

Question: Explain the rationale for choosing Ceftriaxone as the antibiotic.

His condition improved after 4 days of admission and was discharged on 11/3/2017. He was continued with his old medications upon discharge, including T. aspirin 100 mg OD, T. metformin 500 mg BD, T. furosemide 40 mg BD, T. simvastatin 20 mg ON and T. perindopril 2 mg OD. He was also on fluid restriction of 800 cc per day. He will be follow-up his condition in MOPD 1 month after discharge.

Question: Explain the rationale for choosing 800cc of fluids per day as the appropriate voluime for him.

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