UV-GULLAS COLLEGE OF MEDICINE

Department of Internal Medicine

CLINICAL CASE STUDY ASSIGNMENT – CARDIOLOGY MODULE

September 05, 2023

General data and chief complaint:

Patient name: A.R.

Date of admission: August 06, 2023
Source and reliability: Patient and spouse – 90%

A 33-year-old, female, was brought to the emergency room due to cough and dyspnea.

History of present illness:

Two weeks prior to admission, the patient had onset of non-productive cough with no
other associated symptoms. No fever, no dyspnea, no body malaise, no night sweats and chills.
There was no consultation and no medications that were taken. The patient just tolerated the
condition.

One week prior to admission, the patient’s cough persisted now noted to have unilateral
edema on the right leg. Consultation was done at a local private clinic and the patient was
diagnosed with pneumonia. She was sent home and was prescribed with oral antibiotics
Amoxicillin 500mg/tablet 1 tablet orally thrice daily for 7 days. The patient had completed the
regimen for 7 days (21 doses).

In the interim prior to admission, there was noted worsening of the cough now productive
with pink frothy sputum. The patient’s edema also progressed now involving both the right and
left legs. Three days prior to admission, there was also already noted decreasing urine output
with increasing abdominal girth and exertional dyspnea on light physical activity.

Morning of admission, the patient now had dyspnea even at rest. Hence, the patient was
brought to the emergency room and was advised for admission.

Pertinent review of systems:

(+) cough (+) palpitations (+) nausea (+) history of recent pregnancy (-) fever (-) coryza
(-) vomiting (-) rashes (-) neurologic signs and symptoms (-) weight loss
Past medical, family and social history:
• Non hypertensive, non-diabetic, non-asthmatic. No known psychiatric illness
• Patient is G1P1(1001), uncomplicated pregnancy
• S/P Cesarean section (March 25,2023)
• No other history of previous admission and surgeries
• Nonsmoker, nonalcoholic beverage drinker
• No known illicit drug use, no tattoos
• No recent travel history
• Unrecalled recent vaccinations
• The patient is unemployed and has had a sedentary lifestyle, poor dietary habits and
living condition. The patient is married and currently living in an apartment with her
spouse.
• Heredofamilial diseases include hypertension on paternal side

Physical examination:

General survey: Awake, alert, coherent, afebrile, with occasional dyspnea (unable to
measure the weight and height, however patient seems to appear as obese)
Vital signs: BP 130/80, HR 105 bpm, RR 22 cpm, T 36.6C, O2 sat 96% RA
Skin: No lesions, no jaundice, (+) surgical cesarean scar, no rashes, warm, good turgor
HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, moistened lips and
tongue, non-hyperemic tonsils
Neck: engorged neck veins, thyroid gland not enlarged, no palpable lymph nodes
C/L: intermittent bi basal rales with no wheezing
CVS: distinct heart sounds, (+) tachycardia, regular, no murmur, displaced apex beat,
(+) heaves/thrill
Abdomen: (+) increased abdominal girth, NABS, soft, nontender, no organomegaly, DRE
unremarkable
Extremities: strong peripheral pulses, (+) bipedal edema, grade 1

CLINICAL QUESTIONS:

1. What is your primary working impression/ diagnosis (5 points). Give supporting

evidence of your diagnosis (5 points).

Primary working impression/diagnosis: Congestive heart failure (CHF)

Supporting evidence:
1. Patient presents with dyspnea, cough and pink frothy sputum, which are classic
symptoms of CHF.
 2. Progressive bilateral leg edema suggests fluid retention, a common finding in CHF.
3. Decreasing urine output and increasing abdominal girth are also suggestive of fluid
overload and CHF.
4. Engorged neck veins and displaced apex beat are signs of right-sided heart failure,
which can occur in CHF.
5. Intermittent bi basal rales with no wheezing suggest pulmonary congestion, which is
another classic sign of CHF.
6. Tachycardia and heaves/thrill are signs of a stressed and enlarged heart, which can
occur in CHF.

2. Give at least 3 differential diagnoses and give the bases. (15 points)
1. Pneumonia: Although the patient completed a course of antibiotics for
pneumonia, the progression of symptoms and development of new symptoms,
such as dyspnea and bilateral edema, raise the possibility of continued or
recurrent pneumonia. A chest x-ray can help differentiate between pneumonia
and CHF as the cause of the patient’s symptoms.

Pulmonary embolism (PE): PE can cause sudden and severe shortness of breath,
coughing, chest pain, and sometimes wheezing. The unilateral edema noted earlier
may also be suggestive of a DVT, which can be a precursor to a PE. PE can present
similarly to CHF, with pulmonary congestion and respiratory distress, so a CT
angiography may be done to rule out PE.

Acute respiratory distress syndrome (ARDS): ARDS results from acute lung injury due to
various causes such as infection, trauma, and aspiration, among others. The cardinal features
of ARDS are severe hypoxemia, diffuse bilateral pulmonary infiltrates, and respiratory failure
with dyspnea, cough, and tachypnea. ARDS can be differentiated from CHF with additional
testing, such as arterial blood gases, chest x-ray, and CT scan.

3. What work-up diagnostic imaging and laboratory tests are you going to perform in this
case and give the rationale. (15 points)

- CBC with differential: To evaluate for any signs of infection or other underlying hematologic
conditions such as anemia.
- Comprehensive metabolic panel (CMP): To assess liver and kidney function, electrolyte
levels, and calcium levels.
- Troponin I: To assess if there is any cardiac damage or injury.
- Brain natriuretic peptide (BNP): To assess for possible heart failure.
- Thyroid-stimulating hormone (TSH), free T3, and free T4: To assess thyroid function.
- Chest X-ray: To assess for any signs of pulmonary congestion, pneumonia, or other lung
pathology.
- Electrocardiogram (ECG): To evaluate for arrhythmias or evidence of cardiac ischemia.
- 2D echocardiogram with doppler studies: To evaluate the structure and function of the
heart and assess for any valve abnormalities, ventricular hypertrophy, or other cardiac
pathology.

4. Interpret the laboratory and imaging studies provided (20 points):

Lab chemistries 8/06 Normal range

Creatinine (eGFR 118) 0.67 M: 0.8-1.3/ F: 0.6-1.2

mg/dl
BUN 20 12.9-42.9 mg/dl

SGPT/ALT 125 M: <45/ F: <34 u/L

K 3.7 3.5-5.5 mmol/L

Mg 2.47 1.8-3.0 mg/dl

Ionized calcium 1.14 1.13-1.31 mmol/L

Na 130 135-145 mmol/L

Troponin I 0.15 < 0.3

BNP 17,958 < 125 pg/mL

Albumin 3.3 3.5-5.5 g/dL

Procalcitonin 0.24 < 0.5 ng/ml

TSH 3.94 0.3 – 5.0 mIU/L

FT3 1.94 0.8 – 2.0 ng/mL

FT4 13.2 11.0 – 22.5 pmol/L

CBC 8/06 Normal range

WBC 10 4.5-13.5 X10/L

2D echo with doppler studies:
HGB 13.8 12.0-16.0 g/dL • Eccentric left ventricular hypertrophy with global
hypokinesia with severe systolic dysfunction (EF of
26% by Modified Simpson’s rule) and with evidence of
HCT 44 36-47% grade 3 diastolic or severe left ventricular diastolic
dysfunction indicative of a severely increased filling
PLT 539 150-440 X10/L pressure.

NEU 62 50-75%

LYM 31 20-35%
- Elevated SGPT/ALT: This indicates liver injury or inflammation.
- Low potassium (K): This can cause muscle weakness, fatigue, and arrhythmias.
- Elevated troponin I: This suggests cardiac injury or damage.
- Elevated BNP: This supports the diagnosis of heart failure.
- Eccentric left ventricular hypertrophy with global hypokinesia with severe systolic
dysfunction (EF of 26% by Modified Simpson’s rule) and with evidence of grade 3 diastolic or
severe left ventricular diastolic dysfunction: This indicates significant damage to the heart
muscle and impaired function.

5. With the laboratory and imaging studies, what is/are the complete final diagnosis/es of
the case and give basis? (20 points)
The complete final diagnosis in this case is severe systolic and diastolic heart failure
with left ventricular hypertrophy. The laboratory and imaging studies all point to a
cardiac etiology of the patient’s symptoms, with evidence of cardiac damage and
severe impairment in cardiac function.
6. Make a concept map (from patient’s clinical history thru arriving at the final diagnosis)
(15 points)
 7. What is your ER management and the rationale. Give preventive measures to educate
the patient. (5 points)
ER management includes the following:
– Oxygen therapy to improve oxygenation
Diuretics to decrease fluid overload
– Nitrates or other medications to improve cardiac function
- Monitoring for signs of worsening heart failure or arrhythmias
– Education about diet and medication management to control heart failure symptoms
– Referral to a cardiologist for further management and treatment.

Preventive measures to educate the patient include lifestyle modifications such as regular
exercise, a heart-healthy diet, and smoking cessation. Medication adherence and regular
follow-up with a cardiologist are also important for long-term management of heart failure.

Deadline of submission: September 20, 2023

Case study feedback/ discussion: September 25, 2023