Case File

[filipinaMD]

Hi to everyone. I'm kind of new to the forum and i do hope I am posting in the right section. I would like to ask for an assistance regarding an upcoming case presentation because it seems to me that my diagnosis isn't right, but I'm thinking it's right-sided heart failure.
I know this is a desperate move but I am nearing my case presentation date
The .doc file of the case can be downloaded here.

http://www.mediafire.com/?t2g5zz0egacog8o

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[joejabjab]

I didn't think about it too thoroughly, but briefly, it sounds like the patient has bilateral pleural effusions due to malignancy (as described; most likely lung cancer (smoking history and the patient was found to have a left lung mass) or lymphoma (previous neck mass that was suspicious for malignancy, now with enlarged parabronchial lymph nodes).

A malignant process can cause the pleuritic pain the patient describes, his chronic cough, and ultimately his hypoxia due to pleural effusions. If the malignancy involved his heart, it can explain his elevated JVD and right heart failure symptoms (anasarca/edema).

The patient also has a concomitant pneumonia which may have led to his demise as well (fever, cough, septic like hospital course.

 

[Maximuss]

Hi to everyone. I'm kind of new to the forum and i do hope I am posting in the right section. I would like to ask for an assistance regarding an upcoming case presentation because it seems to me that my diagnosis isn't right, but I'm thinking it's right-sided heart failure.
I know this is a desperate move but I am nearing my case presentation date
The .doc file of the case can be downloaded here.

http://www.mediafire.com/?t2g5zz0egacog8o

This guy is alcoholic and presented with a anasarca...has nothing to do with right sided hear failure, but decompensated liver failure. Assuming an INR of 2 to 2.5 (data is missing), his MELD score is about 28%, which means a 54% mortality at 3 months (very bad prognosis).
His fever can be explained by SBP (was a paracetesis performed?), pneumonia, or post obstructive pneumonia (from a lung tumor)..
This case is unlikely a cardiac case and should be posted elsewhere. Good luck for your presentation and let us know who it goes..

 

[KaLiMaN]

This guy is alcoholic and presented with a anasarca...has nothing to do with right sided hear failure, but decompensated liver failure. Assuming an INR of 2 to 2.5 (data is missing), his MELD score is about 28%, which means a 54% mortality at 3 months (very bad prognosis).
His fever can be explained by SBP (was a paracetesis performed?), pneumonia, or post obstructive pneumonia (from a lung tumor)..
This case is unlikely a cardiac case and should be posted elsewhere. Good luck for your presentation and let us know who it goes..

You're not in cardiology and already have an attitude. The case has interesting cardiac findings and is a good teaching case for differential diagnosis for a medical student

 

[KaLiMaN]

Hi to everyone. I'm kind of new to the forum and i do hope I am posting in the right section. I would like to ask for an assistance regarding an upcoming case presentation because it seems to me that my diagnosis isn't right, but I'm thinking it's right-sided heart failure.
I know this is a desperate move but I am nearing my case presentation date
The .doc file of the case can be downloaded here.

http://www.mediafire.com/?t2g5zz0egacog8o

I agree this patient has predominant right-sided HF symptoms, I think constrictive pericarditis should be in your differential and given the origin of the patient, chronicity of the HPI, lymphadenopathy and mass-like lung lesion on x-ray, TB should be high in the differential. I guess lung cancer can also infiltrate the pericardium. Now the cause of death could have just been a superimposed infection leading to septic shock and death.
I think other possibilities include alcoholic dilated cardiomyopathy with lung cancer and superimposed pneumonia.

 

[KaLiMaN]

I agree this patient has predominant right-sided HF symptoms, I think constrictive pericarditis should be in your differential and given the origin of the patient, chronicity of the HPI, lymphadenopathy and mass-like lung lesion on x-ray, TB should be high in the differential. I guess lung cancer can also infiltrate the pericardium. Now the cause of death could have just been a superimposed infection leading to septic shock and death.
I think other possibilities include alcoholic dilated cardiomyopathy with lung cancer and superimposed pneumonia.

Finally Maximus' differential is certainly possible, liver failure from alcohol with an underlying lung malignancy. In this setting the final infectious event could have been pneumonia or SBP as he mentioned

 

[Maximuss]

You're not in cardiology and already have an attitude. The case has interesting cardiac findings and is a good teaching case for differential diagnosis for a medical student

Im sorry but where did you see my attitude??
Again, common things being common, this is likely signs of liver failure and portal hypertension, rather than right-sided heart failure..Regardless, the patient needs an echo which i believe was not reported here.
Again, let us know who the presentation goes..good luck!

 

[filipinaMD]

Wow. I'm very much delighted for the very warm responses. Just a quick realization though.. anyone considering Cor Pulmonale as the diagnosis? Any thoughts? Again, thank you guys for the differential. It's helping me so much as i progress on the case.

 

[KaLiMaN]

Wow. I'm very much delighted for the very warm responses. Just a quick realization though.. anyone considering Cor Pulmonale as the diagnosis? Any thoughts? Again, thank you guys for the differential. It's helping me so much as i progress on the case.

Cor Pulmonale is very unlikely without a history of severe COPD, Sleep Apnea, or any other known pulmonary condition to cause pulmonary artery hypertension. I did not see that in your case. Many cardiac conditions can lead to pulmonary HTN, however, by definition that would not be considered Cor Pulmonale.

 

[filipinaMD]

Cor Pulmonale is very unlikely without a history of severe COPD, Sleep Apnea, or any other known pulmonary condition to cause pulmonary artery hypertension. I did not see that in your case. Many cardiac conditions can lead to pulmonary HTN, however, by definition that would not be considered Cor Pulmonale.

Thanks. But what do you think though is the cause of the nonproductive cough descried in the HPI?

 

[KaLiMaN]

Thanks. But what do you think though is the cause of the nonproductive cough descried in the HPI?

One possibility it's an increment in the left ventricular end diastolic pressure leading to alveolar congestion. Although, this patient has a lung mass, which by itself can cause non-productive cough.

 

[nickolas]

To me this seems decompensated heart failure due to pneumonia, maybe post obstructive pneumonia. Was his liver cirrhotic on palpation? If not then it is not liver failure from alcohol but right heart failure.
He could have Cor Pulmonale secondary to COPD though his history I think is not typical of COPD (then again maybe cigarette coughing maybe considered normal by smokers)

Most probable diagnosis is non ischemic cardiomyopathy, probably due to alcohol toxicity on the myocardium.