Case discussion on myocarditis

THIS IS AN ACTIVE CASE DISCUSSION RELATED TO MYOCARDITIS

Details of the case are present in the following link https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1and my analysis of the case is present in the following linkhttps://medcases.blogspot.com/2020/05/heart-failure.html

Case discussion

[30/05/20, 4:22:19 PM] Student7: 

Few doubts i got while writing the case:

1.Is the mitral regurgitation in this case secondary to left ventricular dysfunction or is it the regurgitant valvular disease that is causing the heart failure?

2.What are the long term complications of using diuretics?

[30/05/20, 4:32:57 PM] Student23: Mitral regurgitation in this case is due to left ventricular dilatation (which is due viral myocarditis) which stretches the mitral valve anulus causing valvular insufficiency

[30/05/20, 4:33:16 PM] Student23: https://www.cardiomyopathy.org/news--media/latest-news/post/420-mitral-valve-regurgitation

[30/05/20, 4:39:17 PM] Student7: 

[30/05/20, 4:46:42 PM] Student24: Regarding your question 2.

"The most worrisome effects of diuretic therapy have revolved around hypokalemia and its relationship to cardiac arrhythmias and sudden death."

https://www.ahajournals.org/doi/pdf/10.1161/01.HYP.11.3_Pt_2.II16

[30/05/20, 5:07:34 PM] Post Residency PG1: What is the evidence that she has mitral regurgitation?

[30/05/20, 5:07:50 PM] Post Residency PG1: Ask the treating team to share her Echo video

[30/05/20, 6:23:13 PM] Student1: Things which I did not understand in this case are:

1)Why was Anti-malarial drug prescribed for him if it was a simple viral fever? Why not Paracetamol/ Ibuprofen?

2)What were his auscultatory findings?

[30/05/20, 8:19:14 PM] Post Residency PG1: 1) unfortunately people are prescribing it for the big virus troubling mankind the most now 

2) We have the patient's number if any of you can help us take a better history. Also the auscultation point is giving me an idea. Can we collect the patient's heart sounds also through his mobile phone by asking him to place it in different locations of his chest?

[30/05/20, 8:25:00 PM] Student1: Sir there are studies which say that Chloroquine can cause cardiomyopathy. So could that be possible in this case? Assuming he was prescribed chloroquine.

[30/05/20, 8:26:00 PM] Student2: He was prescribed Choloquine according to a PG Maam.

[30/05/20, 8:26:45 PM] Student1: Okay. So could that be the cause?

[30/05/20, 9:31:25 PM] Post Residency PG1: Share one such study

[30/05/20, 9:32:04 PM] Post Residency PG1: Quote the relevant portion

[30/05/20, 9:38:18 PM] Post Residency PG1: There are no numbers here. How many patients received chloroquin? How many developed cardiomyopathy? Need more study details

[30/05/20, 9:43:29 PM] Student1: Fewer than 20 cases of chloroquine cardiomyopathy have been reported. In our case, we observed an association between two cardiac complications of chloroquine toxicity: conduction disorder and hypertrophic cardiomyopathy. This pathology has been

[30/05/20, 9:43:42 PM] Student1: https://heart.bmj.com/content/81/2/221

[30/05/20, 10:05:21 PM] Post Residency PG1: Is this a quote from the link below? 

[30/05/20, 10:48:49 PM] Student1: Yes sir

[30/05/20, 10:52:08 PM] Post Residency PG1: Does our case fit with the case described here?

[30/05/20, 11:02:16 PM] Student1: No sir it mainly shows the long term effects of chloroquine

[30/05/20, 11:04:39 PM] Post Residency PG1: Will be looking forward to your finding a chloroquin study that demonstrates acute cardiac damage similar to what our patient had. Any takers for direct history taking in this patient through telephone including his mobile phone auscultation data?

[31/05/20, 12:15:34 AM] Student1: I will find it out sir.

[31/05/20, 8:18:04 AM] Student2: https://caseopinionsbyrollno156.blogspot.com/2020/05/fighting-for-breath.html

Some doubts: 

1.What was the dosage of Chlorquine given to him? What was the treatment he recieved for improvement from Grade 3 NYHA to grade 2?

2. Why is there presence of early inspiratory crepts in this patient with pleural effusion, when early inspirtaoy crepts indicate Chronic Obstructive Pulmonary Disorders?

3. Why did pleural effusion occur and not pulmonary edema when mechanism of rise of backflow pressures from left atrium is the same in both?

4. Why was no chest X-ray taken to better understand the lung pathology?

5. How was a severe Mitral reguritation hidden? There was no systloic murmur neither any characteristic ECG changes?

[31/05/20, 9:08:30 AM] Post Residency PG1: These are excellent questions Dr Sri Valli. 

Let all the students share their answers and please ask the CR to share it with all the interns and PGs. Once there is a discussion I shall provide all the answers. 

The first question around dose can be also answered by the patient. Let me know if you want to ask him and I shall PM you his number. 

One of the major deficits in our Intern logged history (and I'm sure it will be the same for most of our students UG and PG) is that the entire story of the patient is hardly ever captured and there always remain gaps. 

So informational continuity with the patient is very important.

[31/05/20, 10:28:36 AM] Student2: Yes sure sir. Please send me his number.

[31/05/20, 12:25:55 PM] Post Residency PG1: Have shared his number with three of you. Please be empathetic with him. First introduce yourself as a student doctor working in our department as a member of our team and then gently ask him the questions like a doctor (not like a policeman).

This is actually the most important test of your online training. Let's hope we shall be able to benefit him and our group shall derive more learning insights about him from your inquiries