INTRODUCTION
CASE IN DETAIL
DB was diagnosed with acute myocardial infarction when she presented at hospital 3 months ago with a 2-day history of epigastric discomfort, nausea and general malaise. Her admission was further complicated by an episode of diabetic hyperosmolar coma, which was managed with hydration and parenteral insulin. She was discharged from hospital 9 weeks ago after a hospital stay of 3 weeks. Post discharge she experienced angina on exertion. She could walk 50 metres on flat ground before experiencing retrosternal chest discomfort. Subsequent coronary angiography revealed triple-vessel disease.
She was scheduled for revascularisation therapy through angioplasty and stenting 1 week ago. The treatment had to be postponed due to severe dyspnoea on second presentation. The dyspnoea was present at rest, with associated orthopnoea and episodes of paroxysmal nocturnal dyspnoea. These symptoms have been present in varying degrees of severity over the past 3 months. Currently her ischaemic heart disease is managed with isosorbide mononitrate 60 mg daily, quinapril 5 mg daily and aspirin 150 mg daily. She has a significant risk factor profile for coronary artery disease, which includes:
1. a family history of ischaemic heart disease, with her mother dying of an acute myocardial infarction at the age of 67 and father dying of the same at the age of 65
2. a smoking history of 50 pack-years. She stopped smoking 10 years ago.
3. hypercholesterolaemia managed with pravastatin 10 mg daily. The patient does not know her previous or current cholesterol levels.
4. hypertension diagnosed 1 year ago and managed with diltiazem 240 mg daily. She denies any side effects associated with this medication. The local pharmacist monitors her blood pressure at monthly intervals. She cannot remember the most recent blood pressure reading.
5. diabetes mellitus, which was diagnosed 4 years ago. Initially she was managed on a diet and the oral hypoglycaemic agent metformin. But metformin was very soon stopped due to its adverse effects, including nausea, diarrhoea and rash. Subsequently she was commenced on gliclazide. Three months ago this was stopped due to erratic blood sugar control, and she was commenced on insulin therapy. She is currently maintained on the following insulin regimen:
She monitors her blood sugar levels four times a day. She does not comply with the diabetic diet.
Usually her blood sugar levels fall between 8 and 10 mmol/L. She denies ever experiencing hypoglycaemic episodes and is unaware of the usual warning signs of hypoglycaemia.
She suffers from the multiple end-organ complications associated with diabetes:
1. Ocular complications—an ophthalmologist reviews her eyes every year. She has bilateral cataracts and is awaiting excision. She is unaware of any other ocular complication and denies any visual impairment.
2. Renal complications—she has her urine tested by her general practitioner every month and is currently unaware of any nephropathy. But she complains of recurrent polydipsia, polyuria and nocturia, symptoms that may suggest renal failure.
3. Macrovascular complications—she has peripheral vascular disease and has a claudication distance of 10 metres. She has never had a stroke.
4. She complains of postural dizziness, a symptom that may suggest autonomic neuropathy.
DB denies any paraesthesias or loss of peripheral sensation. She also denies any foot complications such as callosities, corns or ulcers.
She also suffers from asthma, which was diagnosed many years ago, and emphysema, diagnosed 8 years ago.
Her airway symptoms are worst in the winter. Perfumes and pollen are known precipitants of her asthma attacks. She denies nocturnal cough. She has never been admitted to hospital with exacerbation of airway disease. She monitors her peak flow weekly and it varies around 150–200 L/min. Her airway disease is currently managed with nebulised salbutamol and ipratropium bromide four times a day and salmeterol via a metered dose inhaler twice a day. She has been managed on variable doses of prednisolone previously, but she cannot recall the maximum or minimum doses that she has been on.
Prednisolone causes easy bruising but she denies any other side effects associated with this therapy, including pathological fractures and weight gain. She cannot remember whether she has had her bone density assessed.
She was diagnosed with carcinoid tumour of the left lung 8 years ago when she presented with resistant wheezing, dyspnoea and cyanotic spells. She denies any facial flushing or diarrhoea during that presentation. The diagnosis was made after imaging studies followed by bronchoscopy and biopsy. She is managed with regular endobronchial laser therapy at 2-yearly intervals and her last treatment episode was 1 year ago.
She has had persistent diarrhoea for 3 months. On average she has 6–10 bowel movements a day. The diarrhoea is watery in nature and she denies any associated blood loss. She denies any abdominal pain, nausea, vomiting or anorexia. She has previously tried several antidiarrhoeal agents without much success.
She also suffers from painful muscle cramps occasionally, which are treated with quinine bisulfate as required.
Her current medications in summary are diltiazem, isosorbide mononitrate, pravastatin, insulin, salbutamol, ipratropium bromide, salmeterol and quinine bisulfate.
This woman’s allergies include metformin and penicillin, both of which cause rash.
Her family history also includes one brother aged 81 suffering from Alzheimer’s disease and one sister aged 69 suffering from rheumatoid arthritis and breast cancer.
She has previously worked as a chef and is currently on a pension. She finds this income barely enough to meet her needs.
She consumes alcohol only very occasionally.
She has been married for 51 years and her husband, aged 74, is well and supportive. She is usually independent with activities of self-care, but has been experiencing difficulties lately due to the dyspnoea. She lives in a house where there are no steps to negotiate. She has been driving until about 3 weeks ago.
She has a son aged 47 and a daughter aged 44 years; both are well, married and living apart from their parents, and she has four grandchildren. She has regular contact with them.
The dietary history I obtained suggests satisfactory nutrition but with inappropriately high joule and lipid intake.
She has poor sleep hygiene, with initial and terminal insomnia. She has about 5 hours of sleep each day but denies daytime somnolence.
She has had the occasional feeling of depression but has never sought medical help and denies any current depressive feelings.
At home she spends most of her spare time knitting.
I felt that she had very poor insight into the multiple disease conditions that she suffers from.
ON EXAMINATION
DB was alert and cooperative. She had an estimated body mass index of 30. Her cognitive function was well preserved, with a Mini-Mental State score of 29/30. She was breathing oxygen via nasal prongs at a rate of 2 L per minute.
Her blood pressure was 148/68 mmHg and there were postural drops of 20 mmHg systolic and 20 mmHg diastolic. Her respiratory rate was 20 at rest. She was afebrile.
Examination of the cardiovascular system showed a jugular venous pressure elevation to a level 5 cm above the angle of Louis. Her apex beat was not palpable. There were two heart sounds and both were normal with no added sounds. There was bilateral pitting ankle oedema to the level of the knee.
Buy Membership for Internal Medicine Category to continue reading. Learn more here
