A 35 year male patient with shortness of breath and pedal edema

G sai tejaswini
 Roll no :61

I have 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, come up with a diagnosis treatment plan.

 The entire real patient clincal data in this linkhttps://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

 COMPLAINTS:
*  fever -1month back
*shortness of breath- since 2weeks
*pedal edema-since 2 weeks

FEVER: 1month back which was high grade associated with chills
 Probable causes may be -
1. Viral infections
2. Meningitis(no features suggestive)
3. Typhoid(no features suggestive).
4. Malaria.

 Treatment given anti malarials by local rmp.

SHORTNESS OF BREATH:since 2weeks
 Initialy it was NYHA grade 3 but after treatment it became NYHA grade 2,
History of paroxysmal nocturnal dyspnea
Probable causes  may be :
 Cardiac causes

 Pulmonary causes ( no history of cough , cold,  wheeze , so it is ruled out)

 Renal causes (no  feature of  oliguria , facial puffiness it is also ruled out)

 PEDAL EDEMA: since 2 weeks bilateral  progressive in nature  extended upto knee.
Probable causes may be
Cardiac causes
 Renal causes( no features suggestive)
 Liver causes
 
EXAMINATION, INVESTIGATIONS:
 edema upto knees (grade 2)
 Rs:right ISA early inspiratory crepitus is present

JVP : was found to raised 

https://drive.google.com/file/d/1Gr2xuU5bcPUbNmQaPjVlavwn1mFK7gr/view?usp=drivesdk

2D echo findings:
 ejection fraction  is 27 %
  ivc dilated but not collapsed
  mild TR+,severeMR+, trival AR+
  all chambers are dilated.
  global hypokinesia, sevre lv dysfunction
   mild pulmonary artery hypertension
   no MS, AS, PE/LV clot.
USG findings: right moderate pleural effusion  grade 1 fatty liver, mild ascites

https://journal.chestnet.org/article/S0012-3692(16)32070-0/fulltext
 By above features iam thinking  they are cardiac related  features.

ANALYSIS: diagnosis may  be heart failure.

Here patient shows  left , right  sided heart failure features.
So it may congestive cardiac failure.

 ANATOMICAL SITE: heart

PHYSIOLOGIAL DISABILITY: shortness of breath , pedal edema

 PATHOLOGY:  here left ventricular failure
 has lead to increase in backward pressure in  left atrium  which lead to increase pressure pulmonary veins and lead to  lung dysfunction finaly leading to right heart failure causing pedal edema.

Whether the heart failure is  systolic heart failure or diastolic heart failure ?
By the feature of 2D echo  ( ejection fraction is  27%) , it is heart failure with reduced ejection fraction.
Here there is problem in pumping blood  , left ventricular hypertrophy is present.
By this it is heart failure with reduced ejection fraction.
 Causes for  HFrEF:
myocardial infarction (  no history of chest pain, syncope, palpitations  it is ruled out).
 Dilated cardiomyopathy

 CAUSE: due to dialated cardiomyopathy(2D echo findings- chambers are dialated).
Aortic , mitral regurgitation(2D echo findings).
  Etiology for dialated cardiomyopathy ?
 It may due to infections, alcohol  induced.
Patient has history of fever  so  it may due to infections leading to myocarditis.
 Mostly there may be viral etiology leading to this disease.
  DIAGNOSIS : heart failure with reduced ejection fraction  secondary to viral myocarditis.
TREATMENT:
PHARMACOLOGICALLY:

Tab.lasix 80mg...40mg...40mg

Tab.isosorbide mononitrate10mg bd

Tab.hydralazine 25mg

Tab. Telma20mg

Tab.metformin 500mg po od

NON PHARMACOLOGICALLY:

 Reduce physical stress.

Restrict fluid , salt intake

REFERENCES:

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1
https://journal.chestnet.org/article/S0012-3692(16)32070-0/fulltext
 Davidson text book https://www.baptisthealth.com/services/heart-care/conditions/left-sided-heart-failure