49 year-old man diagnosed having HIV 10 years ago. He was not on any anti-retroviral drug or HAART regime. He was an IVDU, stopped one month ago. He presented with left sided chest pain associated with mild shortness of breath and palpitation on the day of admission. He also complained of passing watery loose stool and left lower quadrant abdominal pain 2 days prior to admission. The stool was yellowish in colour, no blood and no mucus. He vomited once on the day of admissionhad but had no fever.
On physical examination, he was cachexic looking. His hydration status was good. His apex beat was deviated. There was grade 2 diastolic mumur heard over the left lower sternal border and collapsing pulse was presence. however, he had no stigmata of infective endocarditis. There was tenderness over left lumbar and left iliac fossa. however, the abdomen was soft, no guarding and no hepatosplenomegaly.
His ECG showed left ventricular hypertrophy, T wave inversion at V1-6. Troponin-T and non specific cardiac enzymes were not elevated at the time of presentation. His FBC and renal profile were normal. Chest X-ray showed cardiomegaly and no other changes.
The other test results were not back.
He was treated as acute coronary syndrome and acute gastroenteritis (HIV related). He was also reffered to optalmologist for checking CMV retinitis.
On the next day, he requested to discharge. His chest pain resolved but still have minimal abdominal pain and diarrhoea. The doctor allowed him to discharge.
DO YOU AGREE WITH THE DOCTOR DECISION?
What do you feel Ho? I am interested in knowing what you think.
ReplyDeleteI am not agree with the doctor's decision. HIV patient who is immunocompromise can present with atypical features for any disease. Even though he had no fever, I still think that we should rule out infective endocartitis, pericarditis or myocarditis. Moreover, we are not sure the the murmur was newly develop or not. Besides that, I would like to know that why he develop T wave inversion in all chest leads. Cardiac enzyme was not repeated. Hence, we can't rule out NSTEMI. Or the generalized T wave inversion could indicate severe IHD because he had cardiomegaly. As a doctor, we can't discharge the patient without knowing the cause. Shouldn't prejudice him because he was IVDU and HIV positive.
ReplyDeleteMoreover, his diarrhea can persist for long period of time and end up with dehydration even sepsis. Shouldn't consider simple acute viral gastroenteritis in immunocompromised patient, it was a diagnosis of exclusion.
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