Staff round presentation Unit of Professor Dr' Afaf Farrag

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Staff round presentationUnit of Professor Dr.
Afaf Farrag

• Professor Dr. Magdy El Serafy.
• Professor Dr. Yasser El Boraey.
• Dr. Shereen Hunter.
• Dr. Mohammad Mahmoud.
• Dr. Hanan Abdel Hafez.
• Dr. Yahia El Sharif.
• Dr. Alaa Haseeb.
• Dr. Mohammad El Said.
• ResidentHany Shehab.
• Resident Mahmoud Abdo.

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Personal history

• Saieed M. Soliman, 53 years old.
• A father of seven, the youngest is 15 years old.
• Owner of a fuel station.
• Born and living in El sharkia.
• History of contact with canal water, and
  parenteral anti-shcistosomal therapy .
• He used to have hubble-bubble 5 times/day for 12
  years, then stopped 1 year ago because of his
  present illness.

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Complaint

• Breathlessness

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Present history

• The condition started 3 years ago with a gradual
  onset and progressive course of dyspnoea (G1?G3),
  palpitation, cough and expectoration.The sputum
  was of moderate amounts ,whitish and has started
  to be blood-tinged one month ago, with no diurnal
  or positional variation.
• All these symptoms are precipitated by effort and
  relieved by rest.
• There is history of mild weight loss but no
  anorexia.

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• No orthopnea, chest pain or wheezes.
• No history of abdominal distension, right
  hypochondrial pain or LL edema.
• No history of fever,night sweating, or
  perception of body swellings.
• No skin rashes or joint pains.
• No symptoms suggestive of liver cell failure.

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Past history

• Diabetic for 4 years on glibenclamide(Daonil)
  tab once daily.
• No history of specific drug intake in the last 6
  months.
• No history of blood transfusion.

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Family history

• No similar condition in the family.
• Negative consanguinity.

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General examination

• The patient is fully conscious, cooperative, of
  average intelligence and lying comfortably in
  bed.
• Vital signs
• Bp 120/80.
• Resting pulse 90 b.p.m,normal character ,average
  volume ,equal on both sides.
• Temp. 37C , afebrile all through the hospital
  stay.

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• 1st degree clubbing.
• Central cyanosis evident from
• Injected conjunctivae.
• Inner surface of the lips.
• Under surface of the tongue.
• Finger tips.

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• No jaundice.
• No lymphadenopathy.
• Neck veins are not congested.
• No palmar erythema ,spider naevi or flapping
  tremors.
• No L.L edema

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Chest examination

• Shape symmetrically elliptical.
• Respiration chest wall moves freely with
  respiration at a rate of 18 /min,regular and no
  use of accessory muscles of respiration.
• Trachea central.
• No chest wall tenderness or palpable rhonchi and
  normal T.V.F .
• Normal vesicular breathing and no additional
  sounds.

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Cardiological examination

• Normal shape of the precordium.
• The cardiac apex is seen and felt in the left 5th
  intercostal space midclavicular line,localized
  ,no special character and no thrill.
• Normal first and second heart sounds.
• No additional sounds and no murmurs.

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Abdominal examination

• Inspection
• Normal shape.
• Right subcostal angle.
• No divarication of the recti.
• Umbilicus normal in site and shape, with no
  impulse on cough no pigmentations.
• No visible veins, hernias, pigmentations or
  visible peristalsis.
• Scar of previous appendicectomy, 5 cm in length,
  healing by 2ry intention.

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• Liver
• Upper border 5th space in Rt MCL.
• Lower border
• Rt lobe 3 cm below costal margin (with deep
  inspiration)
• Lt lobe 10 cm by light percussion below the
  xiphisternal junction.
• - It is firm in consistency, with smooth surface,
  sharp edge and not tender or pulsating.
• Spleen not felt, and resonant Traubes area.
• No ascites detected clinically.

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• Fundus examination revealed
• Multiple small peripheral hemorrhages.
• Normal maculae and discs.

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Summary

• A 53-year-old male with
• - dysnoea
• -couph
• -expectoration
• -palpitation
• -haemoptysis(of recent onset)
• -central cyanosis
• -clubbing
• -mild hepatomegaly

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D.D of central cyanosis

• Pulmonary causes
• COPD ( the most common)
• Bronchial asthma
• Pneumonia
• Pulmonary infarction
• Interstitial pulmonary fibrosis (IPF)
• Granulomatous lung disease
• Pulmonary shunts (hepatopulmonary syndrome).

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• Cardiac causes
• -congenital cyanotic heart disease
• -Eisenmengers syndrome
• -acute pulmonary oedema
• haemogobinopathies
• -methemoglobinemia
• -sulphemoglobinemia

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Investigations
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• Urinalysis
• Normal apart from ca-oxalate .

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CBC

• RBCs 5.47 x 106 /uL.
• HGB 17.8 g/dL.
• HCT 49.5 .
• MCV 90.5 fL.
• MCH32.5 pg.
• PLT 94 x 103 /uL.
• WBCs 5900 /uL.
• B 0
• E 1
• St. 1
• Seg. 46
• L. 45
• M. 7
• ESR 1st hour 35.

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Liver biochemical profile

• Total Bilirubin 1.56 mg/dl.
• AST 84 U (N 0-32)
• ALT 63 U (N 0-32)
• ALP 82 U (N 0-104)
• Total proteins 9.1 g/dl
• Albumin 3 g/dl
• Globulins 6.1 g/dl
• PC 53
• PT 18.8 sec.
• INR 1.67

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• HBsAg Negative.
• Hbs Ab Negative.
• Hb core Total Reactive.
• Hb Core IgM Negative.
• HCV Ab Positive.

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Serum Protein Electrophoresis(SPEP)
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Renal functions

• Urea 25 mg/dl.
• S. Creatinine 0.58 mg/dl.
• Na 144 mmol/l.
• K 4.4 mmol/l.

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• Fasting blood sugar 105 mg/dl
• Postprandial blood sugar 155 mg/dl.
• On diet therapy and glibenclamide

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Chest x-ray

• Normal.

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Spiral CT chest

• No evidence of hilar or mediastinal lymph node
  enlargement,masses or calcification.
• No pulmonary alveolar or interstitial opacities
  are seen with normal areation of both lungs.
• No evidence of pleural effusion ,pleural
  thickening or masses.
• Normal cardiac size and shape with no gross
  abnormality of the cardiac chambres.No
  pericardial effusion.
• Normal appearance of the thoracic aorta and the
  great vessels.
• Normal appearance of the chest wall and dorsal
  vertebrae
• The upper abdominal cuts show ?small G.B stone
  for further evaluation .
• Comment Normal CT chest

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Pulmonary function tests
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E.C.G

• Right B.B.B
  
  
  

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D.D of RBBB

• Congenital heart disease
• -ASD
• -VSD
• -Fallots tetralogy
• -pulmonary stenosis
• Myocardial disease
• -cardiomyopathy
• -Acute myocardial infarction
• -conduction system fibrosis
• Pulmonary disease
• -cor pulmonale
• -recurrent pulmonary embolism
• Normal variant in 1 of
  population

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Echocardiography

• Normal internal dimensions, and global
  contractility of the left ventricle.
• No regional wall motion abnormalities at rest
  study.
• Normal other cardiac chambers and valves.
• No intracardiac masses or thrombi.
• No coarctation of the aorta.
• No pericardial effusion.

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Abdominal ultrasound

• Liver average-sized right lobe(13.3 cm), mildly
  enlarged left lobe(11.5 cm), showing parenchymal
  coarseness with finely irregular surface, hepatic
  veins are attenuated, no focal lesions or IHBR
  dilatation, PV 12 mm.
• G.B average-sized but thickened wall, with few
  small calculi inside measuring 4-6 mm in
  diameter. CBD is not dilated.

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• Spleen Average-sized(10 cm), homogenous
  echopattern.
• Kidneys normal.
• Pancreas free.
• No sizeable lymphadenopathy.
• No ascites.

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Conclusion

• Liver cirrhosis.
• Calcular gall bladder.

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Upper endoscopy

• Esophagus 3 cords of grade 1-2 esophageal
  varices.
• Stomach mucosa of the fundus, body and antrum is
  hyperaemic and edematous with mosaic pattern.
  There are several scattered antral erosions.
• Pyloric ring Normal.
• Duodenum free down to D2.
• Conclusion
• G1-2 esophageal varices.
• Portal hypertensive gastropathy.

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?
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Arterial Blood Gases(A.B.Gs)

• PH
• PCO2
• PO2
• HCO3
• O2 sat.

• While pt ? flat
• 7.45
• 25.2
• 47
• 17
• 86

• While pt ? sitting
• 7.44
• 23
• 38
• 15.8
• 77

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Orthodeoxia
Hypoxemia
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Contrast-enhanced echocardiography (CEEC)

• Contrast study by injecting hand-agitated saline
  was done.
• The contrast was seen filling the right
  atrium(R.A) then the right ventricle(R.V).

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• After 5 beats..
• The contrast was seen
• in
• the left atrium (L.A.)
• and
• the left ventricle (L.V.)

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Positive bubble study.
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Technetium-labelled macro-aggregated albumin
perfusion lung scan

• The striking feature of this scan is the
  homogenous visualization of brain activity
  denoting right to left tracer shunt.
• Both lungs portray uniform tracer distribution.

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Comment

• - Technetium-labelled macro-aggregated albumin
  should be trapped in normal pulmonary
  circculation.
• - Tracer activity in the kidney,liver,spleen or
  thyroid is less specific than tracer activity in
  the brain for pulmonary capillary vasodilation
  and A-V shunting
• - Technetium,released due to poor labelling,may
  exhibit tracer activity in any organ except the
  brain.
• - Technetium cannot cross the blood-brain-barrier(
  BBB)
• - Technetium bound to albumin can cross BBB.
• - Technetium bound to albumin is present in
  systemic circulation only in case of pulmonay
  capillary vasodilation and pulmonary A-V shunting
  .

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Brain tracer activity (100 specific)
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Why Hepatopulmonary Syndrome?
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In the absence of intrinsic cardio-pulmonary
disease..

• The three criteria needed for the diagnosis are
  fulfilled
• 1-Chronic liver disease.
• 2-Positive bubble study(CEEC)
• 3-Abnormal oxygenation(PaO2 lt70 MMHG)
  orthodeoxia.

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Thank You