HEART FAILURE 3

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 diagnosis with a treatment plan.

You can find the entire real patient clinical problem in the following link:
https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1

Following is my analysis of the patient's problem. The problems in the order of priority I found are:

• Dyspnea since 15 days
• Pedal edema since 15 days
• Palpitations since 1 year

DYSPNEA

Patient presented with shortness of breath since 1year, which has increased from past 15 days( NYHA class 3).

Based on history and examination

• No history of cold.There is history of dry cough without expectoration and wheeze was present.On examination respiratory system was normal.
• No history of facial puffiness,increase in frequency  or urgency of urination,hematuria. There is history of oliguria. So there is no renal involvement.
• No history of chronic use of drugs such as NSAIDs, steroids.
• No history of muscle pain,muscle loss, tingling and numbness.This excludes neuromuscular involvement.
• Not a known case of diabetes mellitus
• No history of PND and orthopnea. It was associated with palpitations.Patient presented with pounding type of palpitation in the middle of the chest which was gradual in onset and it was exertional and relieved on rest.

From the above features,I think there might be cardiac pathology.

Pedal Edema

Patient presented with progressive bilateral pitting type of pedal edema upto knee.

Differential diagnosis for pitting type of pedal edema are:

• Heart failure 
• Kidney failure 
• Liver failure

Based on history and examination

• No history of periorbital edema,no burning micturation or urgency . There is history of oliguria .
• There is no history of ascites..so there might not be hepatic pathology.

From the above details I think there is cardiac pathology.

After analyzing the above complaints , I am opinion that it is HEART FAILURE. Is it Left heart failure or Right heart failure?????On further examination of CVS,

• Apex beat is present in the 5th intercostal space in the midclavicular line.
• Right ventricular heave is present
• Loud P2 is present
• JVP is raised with prominent a wave.

From the examination finding,I think it is RIGHT VENTRICULAR FAILURE .What could be the reason behind Right ventricular failure???

On further investigation,

• 2D ECHO - Right atrium and Right ventricle are dilated,IVC shows mild dilatation.Normal ejection fraction.Mild TR and AR present.

                   

• ECG-

• CHEST X RAY-

• LFT-

• RFT

• CUE

From the above investigation, I am of the opinion that it is Right ventricular failure with pulmonary artery hypertension.

Some of the other findings in the patient are

• He has hypogonadism

• On CNS examination, there is decreased power in proximal lower limbs.High stepping gait is seen.

Some of the questions that should be answered are:

• IS IT MYOPATHY OR NEUROPATHY ??? As high stepping gait is seen in neuropathy but proximal lower limb involvement is seen in myopathy.
• IS IT A GENETIC PROBLEM AFFECTING ENDOCRINE,CNS AND HEART???