Arvindran 021303075 group D1
 
Case 1
 
History
69 years old Malay male, from Muar who owns a bookstore admitted on 12/06/06 with complaints of difficulty in breathing and wheezing for 1 day. Patient had this problem recurrently for past 10 years(intermittent episodes).
 
Difficulty in breathing :
Sudden in onset
Not associated with exertion, exposure to allergen
Got history of orthopnea (patient used to sleep with 2 pillows)
Associated with wheezing and chest tightness
No history of cough with expectoration, fever, pleuritic type of chest pain, palpitation, pedal edema,abdominal distension, right hypochondrial pain
 
Past history :
Undergone CABG in IJN on 1990.
Diagnosed to have diabetes mellitus and hypertension since 2002.
 
 
Important positive findings on examination :
 
JVP raised (around 8cm)
Pulse – 100 beat/minute, normal rhythm, volume, character and no vessel thickening
B/P – 150/100 mmHg
Respiratory rate – 40breath/min
 
Inspection :
Using accessory muscles of respiration
Intercostal withdrawing
 
Palpation :
Respiratory movement decreased on all area
Vocal fremitus decreased on anterior aspect of left side of chest
 
Percussion :
Dull note on right and left infrascapular area and right and left lower lateral aspect of chest
 
Auscultation :
Normal vesicular breath sound with rhonchi in all area.
Bibasal crepitations present
Breath sound diminished on right and left lower lateral aspect and right infrascapular area.
Vocal resonance decreased on anterior aspect of left chest.
 
 
Diagnosis :
COPD (Chronic Bronchitis) with congestive cardiac failure with bilateral pleural effusion.
 
Reasons ;
COPD – obstructive respiratory problem for long duration (10 years) and commonly lead
               to cor-pulmonle.
 
Congestive cardiac failure
-         JVP raised (right heart failure may be due to lung disease)
-         Dyspnoea, orthopnea, basal crepitations (left heart failure maybe due to hypertension or previous myocardial infarction-patient had CABG)
 
 
Pleural Effusion
-         may be as a complication of heart failure (transudative)
 
 
Follow up : (13/06/06)
-         pulse – 80/min
-         BP – 120/70 mmHg
-         Respiratory rate – 28/min
 
 
On examination patient look better compare to the day before. All the findings are same like the day before except no rhonchi on auscultations.
 
Patient also complain of blurring of vision on both eyes. On examination of eyes, patient had immature cataract on left eye. Patient had ACIOL with conjunctival filtering bleb on right eye. According to patient he has undergone cataract surgery  1 month ago. Blurring on this right eye probably due to :
-         Normally vision return to normal level post operatively after 1month
-         Patients eye drops finished 3days ago and he not yet got the new eyedrops
-         Preexisting diabetic retinopathy – vision not return to normal coz lesion in retina.
 
Management for the patient :
 
-         Oxygen supply
-         Bed end elevation
-         IV lasix
-         Nebuliser – Ipratropium bromide + Salbutamol
-         Salt restriction and water intake restriction
-         T.provastatin OD
-         T.Ticlid 20mg OD
-         T.Isordil 10mg tds.
-         T.Amlodipine 1omg OD
-         T.Spironolectone 25g BD
-         Digoxin 0.0625mg OD
 
 
 
 
Case 2
 
History
61 years old Chinese male, from Muar who is retired policeman and had undergone CABG(on 2003)  admitted on 13/06/06 with central chest pain for 4days. The pain was sudden in onset, retrosternal, intermittent, pricking type of pain. Patient had 5-6 episode of pain every day with each episode lasting more than 20minutes. It was associated with nausea and sweating. It not associated with breathlessness and palpitation. The pain was not relieved by rest..
 
Past history
Patient is having diabetes mellitus and hypertension for past 10years.
 
Examination :
Pulse – 80 beat/minute, normal rhythm, volume, character and no vessel thickening
Respiratory rate – 16/minute
Temp – Afebrile
B/P – 120/80 mmHg.
 
No abnormal findings on cardiovascular system examination.
 
Diagnosis :
 
Unstable angina with history of CABG.
 
 
Management :
Admit the patient
Administer aspirin,oxygen, GTN, and beta-blockers
Anticoagulation – Unfractionated heparin
Thrombolytic agents is contraindicated.
Routine use of calcium channel blockers is not recommended.