AYUTHU SHRIYA 13

                    MEDICINE E LOG 
       35 YEAR OLD MALE PATIENT WITH   HEART FAILURE

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link here..
.
.
 http://hitesh116.blogspot.com/2020/05/elog-14th-may-2020.html

Following is my analysis of this patient's problem:

The problems in order of priority I found are 

1) Shortness of breath since2 weeks
2) pedel edema since 2 weeks
3) Fatigue since 2 weeks
4) Fever
5) Generalised weakness

SHORTNESS OF BREATH
- From 2weeks 
- Initially NYHA 3 
- After treatment ,now grade 2
- History of paroxysmal nocturnal dyspnea 
( Attacks of severe dyspnea occuring at night and waking the patient up from sleep  )
PEDEL EDEMA
Bilateral pedal edema 
Extending up to knees
Pitting type
Progressive in nature 

Causes of bilateral pedel edema 
🔹cardiac failure
🔹renal failure
🔹nephrotic syndrome
🔹right heart failure
  (cor pulmonale) 
🔹secondary to chronic obstructive     airways dosease
🔹decompensated chronic liver disease
🔹NSAIDS , calcium channel blockers,    beta blockers
 
PAST HISTORY 
🔹No history of similar complaints in the past
🔹Not a known case of       Diabetes,HTN,Epilepsy,CVA,CAD

PERSONAL HISTORY :
🔹Diet - mixed
🔹 Appetite- normal
🔹bowel&bladder habits - normal
🔹H/o alcohol and smoking occasionally
🔹No significant family history

GENERAL EXAMINATION:
well built and well nourished
Afebrile
No
Pallor,icterus,cyanosis,clubbing,lymphadenopathy
Edema upto knees (grade2)
BP:130/80mmhg
PR:80bpm
CVS:s1s2heard
RS:right ISA early inspiratory crepts +
P/A:soft and non tender
CNS:Hmf normal
Cranial nerves intact
Motor system normal
Sensory system normal
No cerebellar signs
JVP of this patient
https://drive.google.com/file/d/1Gr2xuU5bcPUbNmQaPjVIavwn1m-FK7gr/view?usp=drivesdk 
 

 
INVESTIGATIONS
🔹Heamoglobin :15.2
🔹Tlc:9600
🔹Platelet:2.39
🔹FBS:102
🔹PLBS:205
🔹Total cholesterol:150
🔹Triglycerides:87
🔹Hal:33
🔹LDL:72
🔹Vldl:17.4
🔹Urea:24
🔹Creatinine:0.8
🔹Uric acid :6
🔹USG abdomen:
right moderate 
pleural effusion 
grade1 fatty liver
mild ascites
🔹2D ECHO:
-Ejection fraction-27%
-IVC dilated(2.3cm)not collapsing
-mild TR+
-severe MR+
-trivial AR+
-dilated all chambers 
-global hypokinesia
-severe LV dysfunction
-mild PAHT
-no MS/AS
-no PE/LV clot
https://www.verywellhealth.com/the-echocardiogram-1745246 

Above history, clinical examination, investigation suggests that it is due to a cardiac reason 
              HEART FAILURE 

How to diagnose a heart failure
https://youtu.be/LSTHZz8aB2o

And I  think it is of both sides right and left heart failure
... It may be congestive cardiac failure

  
        LEFT SIDED HEART FAILURE 
                         ⬇️
       The left ventricle does not pump blood efficiently. This leads to pressure buildup behind the left side of the heart that, over time, causes the right side of the heart to fail
                          ⬇️
Blood backs up behind the left ventricle into the left atrium, in the lungs, and then eventually into the right ventricle, which also eventually fails. This allows blood to then back up farther into the extremities, the liver, and the other organs
                          ⬇️
       RIGHT HEART FAILURE
                    ↙️       ↘️
Systolic failure   /  Diastolic failure
                            ⬇️
                      By 2D echo
               Ejection fraction - 27%
              ( Systolic failure )

HEART FAILURE DUE REDUCED EJECTION FRACTION

As we now know it is HFrEF , we should find the cause for this.Some of the important causes are:
  • Myocardial infraction
  • valvular heart disease
  • non ischemic dilated cardiomyopathy
Based on the history and examination
  • There is no history of chest pain
  • There is no history of syncope
  • There is no history of palpitations
From this history we can eliminate MI (as there is no chest pain ),MS and AS( as there is no chest pain,syncope,palpitation which are cardinal features).My differential diagnosis is left with NON-ISCHEMIC DILATED CARDIOMYOPATHY and  MITRAL REGURGITATION.
To know the exact cause, investigations that are performed is: 
2D ECHO
As all the chambers are dilated MR and TR are also present.Based on the above findings,my diagnosis is NON-ISCHEMIC DILATED CARDIOMYOPATHY.
What might be the etiology related to it???It could be inflammatory cardiomyopathy or alcohol induced dilated cardiomyopathy.
Patient also has a history of fever with chills 1 month back. So I think there might be some infective cause of myocarditis. To know the exactly which organism is involved, following investigations can be done.
  • ECG 
  • 2D ECHO
  • Serum levels of troponin
  • Creatinine phosphokinase fractions
  • MRI
  • Immunohistochemistry
  • PCR
Since most common cause of myocarditis is due to viral etiology , I am of the opinion it might be viral myocarditis.

TREATMENT

Pharmacological 
  • Tab.lasix 80mg...40mg...40mg
  • Tab.hydralazine 25mg
  • Tab.metformin 500mg po od
  • Tab. Telma20mg
  • Tab.isosorbide mononitrate10mg bd
  • Captopril
  • Candesarten
  • Valcyclovir
  • Gancyclovir
  • Interferon beta
Non pharmacological treatment 
  • reduce physical activity
  • reduce salt intake
  • fluid restriction


REFERENCES
https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

http://hitesh116.blogspot.com/2020/05/elog-14th-may-2020.html



https://youtu.be/4YnJZwbp0eE

https://medcases.blogspot.com/2020/05/heart-failure.html

Thank you


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