heart failure


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 and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link



A brief discussion about this case!
A 35year old male with Chief complaints of:
1. Hight grade fever with chills one month back
2.shortness of breath since 2 weeks
3. Swelling from ankle to knee since 2 weeks

FEVER with chills:
--high grade fever with chills can occur           mostly due to viral cause( can be adeno     virus,flu, Coxsackie virus, echo                     virus,herpes)
--detalied history of fever is required to          know the etiology of virus like 
  Does he had myalgia? Or rashes?                    associated with fever.


SHORTNESS OF BREATH: 
--CAN BE DUE TO 
respiratory cause  or cardiac cause

Respiratory cause: as there was no history of repiratory symptoms like cough with or without sputum,wheez  this is ruled out.

Cardiac cause: this can be cardiac cause because there is a history of paroxysmal nocturnal dyspnoea. 
       --this occurs when left ventricle could not eject the blood causing overload in the left ventricle and in left atrium lead to pulmonary congestion.so when the patient sleeps, there is redistribution of splanchnic circulation and lower extremities towards central circulation which causes further increase in pulmonary capillary pressure leading to DYSPNOEA.

PEDAL EDEMA: 
 In this case pedal edema Can be due to-

--hepatic cause
--cardiac cause


Cardiac cause: can be due to failure of heart to pump adequate blood .

 Hepatic cause: can be because there is a history of fatty liver grade 1 



*During examination, showed                     pleural effusion.
    -- the reason behind this could be due               to accumution of fluid in the                        interstitium which is due to                            pulmonary congestion ---> fluid in the          pleural cavity

2D ECHO SHOWS
*EF - 27% 
*Mild TR +
*Severe mitral regurgitation
*Trivial AR +
* All Chambers are dilated
*Global hypokinesia
*Severe LV dysfunction
* No MS, no AS
*No PE/LV clot
*Mild PAHT


By analysing the history and investigations, the thing that come into my mind is Dilated cardiomyopathy due to viral etiology.

Pathogenesis of DCM: inflammatory

      Entry of organisms through repiratory tract. ---> infects heart which have specific receptors ----> undergoes replication---> myocardial injury by release of cardiotoxic substances and cytokines---> death of the myocytes ---> thinning of the muscle wall and looses it's contractile property---> SYSTOLIC DYSFUNCTION and GLOBAL HYPOKINESIA ( in left ventricle)

-- Due to systolic dysfunction, there is DECREASED EJECTION FRACTION

-- As the left ventricle unable to contract, there is increased preload

-- Mitral regurgitation could be due to distortion of valvular apparatus

-- DILATATION OF RIGHT VENTRICLE occurs as a response to after load presented by secondary pumonary hypertension and then DILATATION of right atrium or may be due to direct injury by the organism 

Other factors contributing to DCM are 
-Diabetes 
- alcohol intake

ECG:


Investigations that to be done are:
-- serum levels of troponin,CPK
--MRI


Treatment:

-- fluid restriction
-- salt restriction
--tab.metformin
-- tab lasix 80 mg
--tab Telma 20 mg
- tab hydralazine 25 mg
-- tab isosorbide mono nitrate 10 mg



Reference:

 
Harrison's principle of internal medicine
















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