Oedematous patients
1) A 50 year old lady presents with increasing abdominal swelling and complains of bruising on her arms.
On examination you find her to be very thin with bruises on her arms and legs of varying ages.
Her Bp 89/70, HR 89, sats 95% on air, resp rate 22.
Her abdomen is distended and you suspect ascites, the abdomen is soft and you can hear bowel sounds. You try to feel for organs but get none. You notice some spots as below on her abdomen…
Her blood results are as follows…
Na 129
K 5.0
BUN 10
Creat 0.9
Bil 6.0
Ast 654
Alk p 450
Alb 1.4
a) What extra history would you like?
b) What examination will confirm ascites?
c) What is the cause of the bruising?
d) What other examination will you make?
e) What is the cause of this ladies oedema?
f) What is your management plan?
2) A 22 year old male presents with shortness of breath of gradual onset.
You listen to his chest and find bibasal crepitations.
Listening to his chest you hear a systolic murmur in the apex region.
He has bipedal oedema and an enlarged liver.
BP 95/57, Heart rate 95bpm, Resp rate 30
Chest x-ray is as follows…
Blood results…
Na 125
K 4.9
BUN 20
Creat 1.7
Bil 1.6
Ast 300
Alk p 200
Alb 2.0
ECG…
a) What extra history would you like?
b) What is the likely murmur?
c) What is your interpretation of the ECG?
d) What is your interpretation of the chest x-ray?
e) What key examination is missing?
e) How do you explain the abdominal pathology?
f) What is your management?
3) A 25 year old female presents after pregnancy with shortness of breath, she has a swollen abdomen.
Her heart sounds are normal and she has bibasal creps her JVP is raised.
Blood results show
Na 127
K 7.0
BUN 120
Creat 12.0
Bil normal
Ast 30
Alk p 126
Alb 3.5
WCC 5.5
Hb 8.0
Plt 120
MCV 67
ECG…
What is the likely cause of the above presentation?
Please interpret the U+E results and ECG?
What type of anaemia is present, what is the likely cause?
What is your management of the patient?
1)
a) Extra history…
Gen history- how long had the problem, any pmh, prev episodes
Then…
Any alcohol intake ? how much for how long
? any hep B/ HIV status, sex work, IV drug use, effected family
Lives near the lake/ haematuria ?schistosomiasis
b)ascites confirmed by shifting dullness and fluid thrill, further confirmed by Abdominal ultrasound.
c) The bruising is caused by the failure of the liver to synthesis clotting factors, this is shown by the decreased albumin
d) As well as shifting dullness and fluid thrill, we will look for jaundice in the mouth and eyes. Prominence of abdominal veins, palmar erythema.
We will also look for signs of alcohol withdrawl…
Resting tremor, anxiety, general agitation
This can be relieved by benzodiazepines and can cause fatal fits.
e) Odema is caused by portal hypertension and poor synthetic function causing hypoalbuminaemia.
f) Tap Therapeutic and diagnostic. Serology for hep B. Abdominal Ultrasound, control any alcohol withdrawal,
Praziquantrel for schistosoma.
2)
a)how gradual symptoms, ? since childhood ? rheumatic fever symptoms ? TB symptoms.
This patient is too young to have heart failure from BP, Smoking, diabetes, calcification of heart valves.
b) Systolic murmur at the apex is likely Mitral regurgitation.
The two most common systolic murmurs are mitral regurgitation(MR) and aortic stenosis(AS).
AS is heard best at the right 2nd intercostals space and radiates to the carotids.
NB. A systolic murmur occurs with the pulse. (feel the pulse as you listen)
c) The ECG is regular sinus rhythm, the axis is deviated to the left, there is left ventricular hypertrophy
d) The chest x-ray shows bilateral pleural effusion, bilateral upper lobe diversion and bat wing shadowing. Suggestive of congestive cardiac failure.
e) We have not performed JVP which os likely raised. We can also look for pedal and sacral oedema
f) Pulmonary congestion is backlogging the blood to the liver causing hepatomegaly and raised LFTs
g) He will need Oxygen, frusemide 40-80mg stat,
Monotoring of input/output
No more than 1.5 L a day. Not for IV fluids
Aspirin 75mg od.
Titrate diuretics against BP/ oedema will need to remain on therapy.
If becomes hypertensive controlBP
ECHO + AUSS
3)
This lady has acute post partum renal failure. Possibilities include hypoperfusion of kidneys during pregnancy, to coagulation problems such as DIC, HUS, HELLP.
The bloods show this lady has renal failure due to raised BUN and Creat.
This has probably caused her hyperkalaemia.
The ecg shows low p waves with tall tented T waves.
She will need urgent calcium gluconate 10ml 10% IV to protect the heart, she will need insulin dextrose infusion.
The anaemia is normocytic and likely due to renal impairment caused by decreased EPO and toxins poisoning the bone marrow
Management
Catheterize, diuretics.
AUSS of renal tract especially ? obstruction of urinary tract ? shrunken kidneys in chronic renal failure.
This patient is in pulmonary oedema and is hyperkalaemic these are two indications for urgent dialysis.
Senior help is needed to insert a dialysis catheter and arrange dialysis.
Provided by T. Whitfield, 2012