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 
https://himabindu5.blogspot.com/2020/05/hello-everyone.html?m=1

Complaints:
 - palpitations since 2months
 - chest pain since 2 months
 - shortness of breath since 2months
 - pedal edema since 1 week

My analysis:
 * Chest pain:
    - since 2months
    - on left side, more on epigastrium
    - non-radiating
    - associated with palpitations
    - associated with shortness of breath and pedal edema
   Not associated with cough,hemoptysis: we can exclude respiratory pathology
   No h/o nausea, vomitings, hematemisis:
peptic ulcer disease can be ruled out (which causes pain in the epigastrium)
   No h/o of joint pains: can rule out musculoskeletal pain
   H/o palpitations, dyspnea, pedal edema: suggestive of cardiac pathology

  * Shortness of breath:
     - since 2months
     - progressive in nature
     - grade 3 - 4 dynspnea
     - associated with PND since 2 months and increased in past 10 days
     - no h/o cough, phlegm, pleuritic pain(respiratory cause); no h/o usage of any drugs; no ptosis (neuromuscular); not a known case of diabetes (metabolic)
    - palpitations: suggestive of cardiac cause( PND: suggestive of left heart dysfunction)
    - decreased urine output(since 1 week): suggestive of renal disease
    - hemogram: microcytic hypochromic anemia which could also be a cause for dyspnea ( due to fluid overload)

   * Pedal edema:
     - since 2 months
     - present bilaterally
     - h/o shortness of breath and oliguria suggests that, pedal edema could be due to cardiac or renal cause(but renal disease mainly present with facial puffiness, in this there is no facial puffiness)
     - in this case, patient complained of chest pain and palpitations first, followed by oliguria: suggesting that heart failure leading to acute kidney injury
 
   EXAMINATION:
    - Pulse: 72 bpm, feeble, irregularly irregular
    - Bp: 110/70
    - Jvp: larger 'a' wave: suggestive of forceful right atrial contraction
      Causes:
       - tricuspid valve stenosis
       - right ventricular hypertrophy
           a) intrinsic rvh
           b) due to pulmonary stenosis
     - Palpation:
        mitral area: apex is displaced downwards and outwards - Dilated left ventricle
         palpable S1: tapping apex beat - characteristic of Mitral stenosis
     - Auscultation:
         loud S1: suggestive of Mitral stenosis
         loud P2: suggestive of Pulmonary hypertension

   INVESTIGATIONS:
    RFT: increased levels of Urea and uric acid - suggestive of acute kidney injury
    LFT: increased levels of total bilirubin, direct bilirubin, SGOT,Alkaline phosphatase
- suggestive of hepatic failure secondary to heart failure

     Chest X-ray:  
Cardiomegaly, enlargement of rt atrium, rt ventricle, Lt ventricle
   2d echo:

    -calcified mitral valves

     -fish mouth appearance 
   
  DIAGNOSIS: Mitral stenosis with heart failure

  Pathophysiology:
  

* Mitral stenosis
            ↓
Increased left atrial pressure
            ↓
Increased pulmonary pressure
            ↓                                    ↓
  Pulmonary congestion.     Increased RV 
            ↓                                  presssure           ↓gas exchange.                      ↓
     & dyspnea                      RV hypertrophy
                                                  ↓
                                             Right sided heart
                                                 failure
 * Prominent 'a' wave in jvp: due to RV hypertrophy

 * Atrial fibrillation in mitral stenosis:
     Increased left atrial pressure --> progressive atrial dilatation --> atrial fibrosis and electrophysiological remodelling -->atrial fibrillations

  * Dilatation of left ventricle in mitral stenosis:
 Cardiac output- decreases in MS --->> which leads to decrease in coronary perfusion
     Heart tries to compensate ↓C.O by ↑HR --->> tachycardia --->> duration of diastole- decreases --->> further compromise coronary supply --->> myocardial ischemia --->> damage to myocytes and myocytes death --->> eccentric fibrosis of myocardium --->> enlargement of LV chamber --->>   ↓ Contractile ability --->> compensation leads to further LV dilatation and negative remodelling

 * Reduced cardiac output in MS -->>   insufficient perfusion to the kidney -->> 
  a) reduced gfr >> oliguria
  b) renal ischemia >> acute tubular necrosis >> oliguria

  * Hepatic failure:
     - hepatic congestion due to right heart failure along with ischemia due to low cardiac output --->> damage to the hepatocytes --->> scarring and cirrhosis


Treatment:
 - Diuretics: to reduce fluid accumulation
 - Anticoagulants: to prevent blood clots formation
 - Beta blockers and calcium channel blockers: ↓HR
 - Anti arrhythmics: to treat atrial fibrillations
 - Surgeries:
  * Percutaneous balloon mitral valvuloplasty
  * Mitral valve surgery
     - commisurotomy
     - mitral valve replacement
 - Life style modifications:
   * Avoiding alcohol and caffeine
   * Fluid and salt restriction

Reference:
https://www.mayoclinic.org › drc-2...
Mitral valve stenosis - Diagnosis and treatment - Mayo Clinic


      
       







   
    

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