29M admitted with chest pain and increase on shortness of breath on background of recent similar admissions in setting non-ischaemic dilated cardiom
29M admitted with chest pain and increase on shortness of breath on background of recent similar admissions in setting non-ischaemic dilated cardiomyopathy
HOPC
- Reports increase shortness of breath and chest pain that has not been settling in last few weeks despite analgesia
- States that morphine is the only pain relief that helps, has been taking endone Q6H at home
- Recently admitted under cardiology and discharged 1/5 with HITH follow-up for INR monitoring while bridging clexane- Despite analgesia reports chest pain and SOB worsening
- Rating current pain 9/10
- Blood pressure also lower than usual for him in last 2/52, sitting persistently SBP 80-90s
- Denies dizziness/postural symptoms despite hypotension
- Has been adhering to FR, reports ~1100mL intake daily but weight 107 kg (up 5 kg since last admit).
- Denies calf swelling/pain, note previous CTPA negative for PE in Feb
PMHx
# Non-Ischaemic cardiomyopathy
- TTE 18/12 - mildly enlarged LV with normal wall thickness + severe global systolic dysfunction EF 27%. Mild mitral regurgitation. Large apical thrombus
- Angiogram 19/12 - normal coronaries
- CMRI 21/12: Dilated LV was severely reduced ejection fraction. LV thrombus present. Normal RV size with reduced apical contraction.
- Commenced on metoprolol XL, spironolactone, dapagliflozin and entresto
# LV thrombus
- noted on CMRI Dec 2023
- thrombus still present on TTE Feb 2024, despite having been on warfarin therapy
- on warfarin - INR aim 2-3.
#Chest Pain of uncertain origin
#fractured C5-7, L5, fell from fence in 2011, nil surg Mx
#childhood asthma
#Dental abscess (new)
Medications (based off recent d/c summary)
Warfarin (coumadin) 6mg daily
Dapagliflozin 10mg mane
Frusemide 40mg BD
Metoprolol XR 95mg mane
Pantoprazole 40mg mane
Pregabalin 50mg nocte
Rosuvastatin 20mg daily
Entresto 24/26 - 1 BD
Spironolactone 12.5mg mane
GTN spray PRN
Endone PRN
SHxHome with mother
Ex smoker- stopped when became unwell
Occasional ETOH
Lives with mum
Recently quit work as waterproofer due to illness
O/E
Looks well, not in obvious discomfort
Warm and well perfused
Obs: BP 88/69, MAP 77, HR 91, SpO2 100% RA, RR 18, afebrile
JVP 4 cm
Heart sounds dual mild systolic murmur
Chest bibasal crackles
Abdo SNT
Calves SNT
Mild lower limb oedema
ECG See below
D/w cardiology registrar on-call Dr James Fahey
- Relayed assessment, given MAP adequate, ongoing issue and asymptomatic happy for altered MET criteria for SBP <80
- Consider titration of diuretics in AM + APS review
Plan
- Admit cardiology
- Altered MET criteria for SBP <80 or symptomatic
- Consider uptitrating diuretics
- Continue warfarin
- Repeat bloods including coags in morning
- Await ICD implantation for primary prevention
- Goal of Care
FBE
Hb113 g/L
WCC9.6 x 10*9/L
Plat374 x 10*9/L
Coags
INR 3.6 H
aPTT37
BiochemSodium130 L
Potassium 4.9
Chloride98
Bicarbonate18 L
Urea 9.8 H
Creatinine 119 H
Estimated eGFR70 L
Calcium 2.32
Calcium Corr2.52
Magnesium0.80
Phosphate 1.41
Bilirubin25 H
ALT75 H
AST103 H
GGT42
ALP104
Protein61
Albumin 28 L
Troponin T High sensitive 15 C15 C16 C
Venous Blood Gas
pH7.41
pCO232 L
Bicarbonate20 L
Base Excess -3.6 L
Lactate 1.8 H
CRP56.7H
CXR
Chest X-Ray
CHEST X-RAY
Clinical Notes:
Cardiomyopathy, shortness of breath, recent pleural effusion.
Report:
Cardiac size is within upper limit of normal.
Perihilar venous congestion.
There are prominent Kerley lines in the right lower zone, which are new
since the previous study. Appearances suggest a mild degree of interstitial
oedema. No large effusion bilaterally.
The rest of the lung fields are clear.
