56yr old female with SOB ( diagnosed with multiple myeloma one year ago and is on chemotherapy)

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

I would like like to thank Dr Rashmitha ma'am and Dr Sreeja ma'am, for providing information and investigative evidences of the case.

Here is the link to Dr Sreeja ma'am's blog :

https://sreejadukkipati97.blogspot.com/2021/01/56f-with-co-chest-pain-generalised.html

This is a case of a 56 year old female, tobacco leaf seller by occupation ,who came to opd  with chief complaints of 

* chest pain since 6 months , pricking type, subsiding on its own, no radiation 

*Shortness of breath grade 2(MMRC) since 1 month progressed to grade 4 since 1 day

*H/o orthopnoea and Paroxysmal dyspnoea and palpitations present 

*No history of cough , wheeze 

*20 days back she developed pain in right eye to which she applied ointment then next day morning she developed redness around orbit, watering eye, pain and tenderness.

*Decreased appetite since 20 days, 

*generalised weakness since 15 days , 

 *Pain abdomen since 10 days. Diffuse predominantly in the epigastric region, non radiating

*B/L Lower limb ,upper limb edema and facial puffiness since 5 days. 

*Edema initially started in the lower limbs then prgressed to upper limbs and then face 

*Palpitations + Syncopal attacks -

Past History:

1yr back patient was brought to the hospital, with complaints of SOB ,sudden hypotension,

(In view of pericardial effusion  )diagnosis of Cardiac tamponade was made 

 FINDINGS:

Pulsus pardoxus present 

Raised jvp 

Muffled heart sounds present

2d echo showed RV diastolic collapse 

So immediately pericardiocentesis was done and about 300 ml of fluid was drained 

Patient gained a sympotomatic relief but immediately after 20 minutes patient has loss of consciousness 

BP : 60/40 mm hg

Immediately IVF one unit 0.9% NS was given as bolus and inj Noradrenaline at 4 ml/hr was started (1 ml = 80 mcg) according to the dilution 

Patient regained consciousness and bp was maintaining at MAP of 60 mm hg and slowly noradrenaline was tapered.

(Etiology of pericardial effusion was thought over and considering Tuberculosis as main cause of etiology 

Malignancy and Tb were the DIFFERENTIALS)

Investigations

Pericardial fluid analysis was sent and according to lights criteria , it was exudative .

Pericardial fluid for Acid Fast bacilli negative and malignant cells negative

Thyroid profile was sent which was subclinical hypothyroidism and started on Tab Thyronorm 50 mcg od

Considering Myeloma defining events : 

 *anemia 

* hypercalcemia.

And 

Considering the high Gamma gap, 

serum protein electrophoresis was sent.

And reports showed: 

Serum protein electrophoresis showing M spike at Beta globulin region

Bone marrow biopsy was done to look for the percentage of plasma cells which were more than 30%

Then provisional Diagnosis of MULTIPLE MYELOMA was made and she was suggested for chemotherapy.

*No history of  DM - II , HTN , Thyroid abnormalities and any other comorbidites

TREATMENT HISTORY:

 Inj Bortezomib

Inj Cyclophosphamide, were given once every 15 -20 days 

Maintanince therapy:

Tab . Dexamethasone 8 mg /od

Tab Septran Ds /BD

Tab Pan 40 mg od

 

She used to develop small Petechial patches around her leg whenever she misses her chemo-sessions. ( as per patient's attender)

Personal history

ADDICTIONS: 

She is an occasional alcoholic ( beer / whiskey) since 35 years. Chews tobacco leaves daily since 6 months.

General Examination:

Patient is conscious coherent and cooperative and well oriented to time place and person.

Pallor +

No icterus, clubbing , cyanosis, lymphadenopathy 

pedal edema present 

VITALS 

Temp - 100 F

PR - 108 bpm

BP - 120/70 mm of Hg

Spo2 - 98% room

SYSTEMIC EXAMINATION

CVS - 

Inspection :

JVP : Raised JVP 

prominent X descent - 14 cms.

No precordial bulge 

 No scars or any sinuses 

Apical impulse in 6th intercoastal space lateral to mid clavicular line 

Palpation :

Comfirmed the inspection findings.

Apical impulse in 6th intercoastal space lateral to mid clavicular line 

Parasternal heave +

Ausculation 

S1 , S2 + 

muffled heart sounds 

Loud P2 in Pulmonary area.

Pansystolic murmur in Tricuspid area.

RESPIRATORY SYSTEM:

 BAE + , fine inspiratory crepts present in right and left ISA

Per abdomen 

 distended , multiple hemorrhagic spots seen. 

Epigastric bulge seen .

Hepatomegaly present with liver span of 15 cm

Tenderness + in epigastric and Right hypochondric area.

 INVESTIGATIONS:

Skin biopsy sample was sent

PROVISIONAL DIAGNOSIS:

 AKI secondary to ?Multiple Myeloma (stopped chemo)  

? Orbital cellulitis ( resolving) 

B/L erythematous rash on legs. (? HSV purpura) 

HFrEF( ? CONSTRUCTIVE PERICARDITIS)

Subclinical hypothyroidism

anasarca resolving

TREATMENT 

1)Fluid restrictions 

2)Lasix

3)Temp charting

4)Strict I/O charting

5)thyroid medications

The patient passed away on Day 7 due to  sudden cardiac arrest.