20 yr old man with pedal edema and palpitations on playing pubg
Hello everyone.. I am sreeram , an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties.
A 20 year old man presented with a 5 day history of pedal edema. The youngest of 4 boys, he was apparently asymptomatic 5months back then he first reported feeling unusual palpitations while lifting a 20L water can onto his bike, a Bajaj Pulsar 150cc. He reports that he had been having such palpitations with exertion even earlier but he could remember only as far back as this event. He reported those palpitations to be bounding and heavy with a feeling of the heart floating in his chest, right in the centre of his chest. In his own words he reported that although he felt they were unusual he ignored this symptom. Indolently progressing for over 2 months, he reported that in the fag end of April, he felt very heavy and bounding palpitations in his chest while lifting a 20L, this time onto his chest and walking with it for a few meters to his bike. As far as he can recall, this was the first time he also felt 'alipiri' (breathlessness). He denied feeling dizzy or having chest pain at that point. He did not have pedal edema at that point. With the lockdown in full swing and colleges still shut down, the patient retorted to playing games on his phone for hours on end, which understandably did not go down well with his family. At no point did he have cough, expectoration or hemoptysis. He also reported unusual palpitations while playing games. They weren't heavy but were associated with a floating sensation in his chest.
He digresses a little and goes into his exploits with liquor and smoking. He told us that one of his family members contested for the MLC elections in March and during the campaigning period he binged on beer (Kingfisher Lite) daily, upto 3 650ml bottles and 3 to 4 mint flavored cigarettes (Editions). With the elections over after an unsuccessful campaign, the patient quit drinking and smoking cold turkey. He retorted to toddy. Frequenting a specific toddy dealer in Urumandala, Chityala, he reported that a few weeks after regularly consuming toddy at that place, he and 3 of his friends all felt pain in their calves which resolved over a few days. He also confided that that a few of his friends had difficulty in walking too. He says apart from the pain, he cannot recall much from that incident. A spontaneous recovery happened.
An avid Poori fan, he has an obsession to eat breakfast daily. 1 week ago, when fate had it that poori wasn't available at his favourite restaurant, he opted for a plate of bonda. He grimaces and says that about 3 hours later he developed severe cramping pain abdomen, localising to his epigastrium, worsening with sitting up or leaning forward. It was associated with acute loss of appetite and constipation for 3 days. He also reported a loss of taste at that point. With the constipation relieving with OTC drugs prescribed by a doctor close to his home, he eventually started having some bowel activity. However he had multiple episodes of vomiting with that spasmodic pain, they were often bilious and non projectile. He felt nauseous before vomiting and eventually hypersalivated and then followed by emesis. Distressed, he consulted a doctor at Nalgonda who only burdened him with more misery by diagnosing him a bowel perforation. Taken aback and dejected, he welled up with tears and his brother eventually brought him to KIMS, with a 3 day history of pedal edema.
With the interview about to end, one last open ended question from me and Dr. Durga Krishna resulted in him revealing something interesting - After quitting smoking and drinking, he went to the gym to bulk up, he reported having bounding palpitations with dumbbells as light as 5kgs and also on short distances on the treadmill. He denied a history of PND or Orthopnea. On direct questioning, he reported bendopnea.
His past medical history is significant for seizures at age 5, for which he took "bottled pills" for about 6 months. They never recurred.
The patient had an active sexual lifestyle 1 year ago. He enjoys a good bottle of toddy with his friends. He hopes to finish his B.Sc in Chemistry and pursue a masters course in Chemistry.
- Above history taken by DR ADITYA GM
20yr old male from nearby village, came with c/c stomach pain since 3days,B/L leg swelling since 2days.
Pt was apparently asymptomatic 5months ago then he developed Palpitation aggrevated on playing pubg and in tension and on lying down not associated with dizziness .had sob on exertion since 10days .
later on 7th day he ate bonda outside followed by pain abdomen Which is spasmodic type for which he took 'ENO' but no relief ,went local hospital where ivf given 2 bottles per
day for 2days.
From 24/08/20:
had vomiting bilious nature 5 episodes for 2days non projectile non bloody .he observed decreased urine output associated with increase lower abdomen distension and increase in B/L leg swelling.
SOB grade 3
On 25/08/20: he had facial puffiness on wakeup went to nearby district headquarters ,where doctor told him that he had hallow viscus perforation.
Same day night he came to our hosp.
No fever, constipation, diarrhea, obstipation, cough ,cold.
History taken by DR SREE RAM ( intern)
PAST HISTORY:
Not k/c/o DM,HTN,Asthma, tuberculosis
PERSONAL HISTORY :
Adequate sleep good appetite
regular bowel and bladder movements
not alcoholic not smoker
GENERAL PHYSICAL EXAMINATION:
Bp 120/70mmhg pr 104bpm , spo2 97% at room air ,afebrile,grbs 128mg/dl
Pallor,no icterus
No cyanosis clubbing koilonychia,generalized lymphadenopathy
pedal edema present pitting type till below knee joint.
Venous pulsations seen.
SYSTEMIC EXAMINATION :
P/A: mild tenderness on deep Palpation in epigastric region.no dilated veins.
Rt hypochondrial tenderness.
CVS :
Inspection- suraprasternal, supraclavicular pulsations seen
On supine epigastric pulsations seen
Palpation- apex beat at 6th ICS ,1cm lateral to midclavicular line
Parasternal heave + diffuse grade 2
Auscultation- ejection systolic murmur at aortic and pulmonary area.wide split heard in neoaortic and tricuspid area.
Soft S1
RS : bae present
EXAMINATION VIDEOS:
https://photos.app.goo.gl/SAefwKjxo5oU23eW8
INVESTIGATION:
Xray abdomen :
HRCT :
Hemogram
hemoglobin 10.7gm/dl
Rbc 3.39mill/cumm
Pcv 30.3 vol%
Mchc: 35.4pg
Rdw cv 15.9%
Tlc 9000
Platelet count 2.53
Lft : tb 1.60mg/dl
Db 0.59mg/dl
Sgot 278 iu/lit
Sgpt 300iu/lit
Alp 153iu/lit
Tp 5.8g/dl
Rft:
Urea 90mg/dl
Creatinine 1.8mg/dl
Uric 11.9mg/dl
Phosp 4.9mg/dl
Na 127mEq/lit
Cl 90
DIAGNOSIS: Right heart failure secondary to idiopathic PAH.
Acute gastroenteritis with hypokalemia resolved with treatment.
TREATMENT given
Fluid restriction <1lit/day
Salt restriction <3.4g/day
INJ CEFTRIAXONE 1G IV BD
INJ METROGYL 100ML IV TID
INJ ZOFER 4MG IV TID
TAB PCM 650MG PO TID
ANXIT 0.25MG/ H/S /STAT
INJ LASIX 5ML IN 45ML NS @8ML/HR
TAB THIAMINE 100MG PO BD
TAB PREGABALIN 75MG PO STAT
DAY 3 :SYP POTCHLOR 10ML IN 1GLASS OF WATER I/V/O HYPOKALAEMIA
DAY 4 INJ.OPTINEURON 1 AMPOULE IN 100ML NS IV OD
INJ. 3% NS INFUSION FOR 3 DAYS
Bp/pr/temp chatting 2nd hrly
Strict I/O charting hrly
Grbs 8th hrly
TAB PAH 20MG PO BD
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