This case presentation is for an 82-year-old man with a history of chronic congestive heart failure (CCF) and chronic kidney disease (CKD) who presented with sharp left-sided chest pain, abdominal fullness, difficulty swallowing and breathing over the past 5 days. He has a history of lower limb swelling and blisters. Differential diagnoses include heart attack, myocardial infarction, pulmonary edema and pleural effusion. On examination, he appears sick and is lying in left lateral position. Vitals are stable. Lungs have wheezing and heart has murmurs. Lower limbs have edema and ulcer. Investigations include chest X-ray, ECG, urinalysis and CBC. He is started

1. CASE PRESENTATION
BY: AIP DEPARTMENT

2. Introduction
• We are presenting B.A a known patient with
CCF and CKD since 2013, aged 82 years,
Munyarwanda from Nyanga village Bukungwe
parish whose NOK is the son TM admitted on
23/9/2018 at 10:43 am.

3. Presenting complaint
• Chest pain 5/7
• Difficulty in breathing 3/7

4. Hx of presenting complaint
• The patient was being managed on drugs at
home until when he suddenly developed a sharp
left sided chest pain that was agreviated by trying
to stand or walk from bed and relieved by resting,
this was associated with an abdominal fullness
and difficulty in swallowing for 5 days. This was
later followed by difficulty in breathing that was
associated with an increased fatigue and
dizziness for 3 days. This was aggreviated by lying
flat and also during the chest pain which relived
when the patient sleeps on the left lateral side
with head slightly raised.

5. • He also reported a history of lower limb
swelling for 2 months that later develop
painful blisters on the right lower limb filled
with fluid which later had to burst on the way
to the hospital.
• However there is no hx of headache, cough,
fevers, nausea and vomiting.

6. Review of other systems
• Genital urinary system
There is hx of painful urination and lower back
pain 3 years ago when he was diagnosed with
kidney failure at BCH
There is no hx of urine incontinence
No hx of urine urgency, frequency and hesitancy.
No hx of a burning sensation during micturition

7. • Central nervous system
There is a hx of headache and dizziness during the chest
pain for 5/7
No hx of blurred vision
No hx of loss of consciousness
No hx of convulsions
No hx of tingling sensations and numbness.
• Gastrointestinal system
There is a hx of abdominal fullness during the difficulty in
breathing and difficulty in swallowing due to chest pain
There is no hx of diarrhea, constipation and vomiting

8. Past medical hx
• This is the 2nd admission at BCH.
• The first admission was in 2013 when he
diagnosed with CCF.
• The patient reports that he has moved in other
hospitals Mbarara, Mulago on his review dates
and investigations for the same condition since
2013
• There is a hx of an investigations done on
17/9/2018 in Kampala were they diagnosed DVT
on the right leg using Venous Doppler ultrasound
scan.

9. Past surgical hx
The patients reports a hx of blood transfusion
during his management kidney failure in
Mbarara.
However there is no hx of any fractures and
major operations.

10. Family/ Social hx
• He is the 3rd born of the 6 children, married to one wife
with 4 children who are all boys.
• They live in a permanent house with 6 rooms with a
separate kitchen and the animals stay in the Farm yard.
• They normally feed on all types of foods including meat,
matooke, posho, beans, milk and others.
• They collect water from a tap and boil it before drinking.
• There is no hx of any related condition like CCF and CKD
from any family relatives.
• There is a hx of alcoholism and tobacco smoking during his
young age.
• There is no hx of any chronic and genetic illnesses like HTN,
SCD and epilepsy

11. Summary
• We are presenting B A, a known patient with
CCF and CKD who came in complaining of
sharp left sided chest pain associated with
abdominal fullness and difficulty in swallowing
for 5 days that were later followed by difficulty
in breathing associated with increased fatigue,
headache and dizziness. These were
accompanied with lower limb swelling for last
2 months.

12. Differentials and clarifications!!!!!!!

13. Differentials
• Heart attack.
• Myocardial infarction
• Pulmonary edema
• Pleural effusion

14. General examination
• Head to toe
We examined a sick looking old man in bed lying in
left lateral position with the head slightly raised.
The hair is well distributed, eyes are symmetrical to
each other and no discharge from the ear, eyes and
nose. There is no yellowing of the sclera and the
skin, no pallor of the conjunctiva, palms and soles,
no bluishness of the mucous membranes and the
extremities, no finger clubbing, no lymph node
swelling, and no signs of dehydration but however
there is swelling of both lower limbs with some
blisters and an ulceration on the right lower leg.
[AVPU]-A

15. • Vital observations during clerking
Bp=106/76mmHg [systolic(90-120),diastolic(60-90)]
Axillary temp=36.2oC [35.5-37.2oC]
Pulse= 74b/m[60-100]
SO2=95%[95-100]
RR=20c/m
• Anthropometric measurements
Weight= 63 kgs
Height= ???

16. Systemic examination
• Cardiovascular system
The hands are warm and no pallor of the palms and soles.
There is a weak Synchronous radial pulse of 74 b/m.
No splinter hemorrhages
Capillary refill returns less than 2 s
There is a distended Jugular vein
There is grade 2 pitting edema on both legs with an ulceration
on the right lower leg and some blisters on both feet
Apex beat is between the 5th and 6th intercostal space along
the mid clavicular line
Heart sounds 1 & 2 were heard but with added
regular/irregular heart murmurs during auscultation.

17. • Respiratory system
There is a deep breath during exhalation.
The abdomen moves in line with the chest wall
Respiration rate=20c/m
Trachea is centrally located
Equal air entry but with a wheeze in both lungs during
auscultation.
• Per abdomen (P/A)
No abdominal distension.
No surgical scars
There is an immediate muscle guarding on light palpation
There is an abdominal tenderness in all the upper quadrants
Unable to perform deep palpation due to the abdominal
tenderness
Bowel sounds heard on auscultation
• Other systems are unremarkable

18. Investigations
• Chest x-ray
• Urinalysis
• ECG
• CBC

20. Management
• Medical /pharmacological management
Amlodipine 10mg OD
Bisoprolol 5mg OD
Methyldopa 500mg BD
Furosemide 80mg BD
Warfarin 5mg OD
IV Cloxacillin 500mg QID
Salbutamol Nebulizer 5mg in 5mls of N/S 6hrly

21. • Nursing management