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
 https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1


Complaints:
 * Shortness of breath:
    - since 2weeks
    - initially NYHA 3 after treatment now grade 2
    - h/o paroxysmal nocturnal dyspnea
    - generalised weakness from 2weeks
   Causes:
    - cardiac
    - respiratory
    - renal
    - metabolic
    - anemia
    - neuromuscular
    - drugs
    
   - we can exclude  respiratory causes as there is no h/o cough, phlegm, pleuritic pain
   - renal diseases are associated with facial puffiness; in this case, facial puffiness was not there, so we can rule out renal causes
   - no h/o ptosis and fatiguability; so neuromuscular cause can be ruled out
   - metabolic: diabetic ketoacidosis can lead to breathlessness ( blood sugar levels- >250 mg/dl)
      FBS:102 mg/dl
      PLBS:205 mg/dl
     In this patient, sugar levels are <250mg/dl; so we can exclude DKA
  - we can rule out anemia as there is no pallor and Hb - 15.2gm/dl
  - thereb is h/o paraxysmal nocturnal dyspnea: suggestive of left ventricular dysfunction
  
  Pathophysiology:
   Supine position/after lying down
                         ↓
    Venous return- increases
    Redistribution of edema fluid
    Sympathetic tone- decreases during sleep (decreased contractility)
                         ↓
     Normal: Lv pumps out excess amount of blood--> no dyspnea
     Lv dysfunction: cannot pumps out excess blood--> ESV ↑ --> ↑ EDP ---> ↑left atrial pressure --> blood is pushed back into pulmonary circulation --> ↑ pressure in pulmonary circulation --> fluid is pushed into alveoli ---> edema ---> dyspnea

 *Pedal edema:
   - since 2 weeks
   - bilateral, extending up to knees, pitting type, progressing in nature
   Causes:
   - heart failure
   - liver diseases
   - renal disease
   Renal failure mainly causes periorbital edema/ facial puffiness; in this case there is no periorbital edema and renal function tests are normal; so, we can rule out renal causes
   Liver diseases causes ascites mainly; but here there is mild ascites
   Elevated jvp along with pedal edema - suggestive of right heart failure
 
Cause for both breathlessness and pedal edema could be congestive cardiac failure

 Investigations:
  2D ECHO: EF-27%,
         IVC dilated(2.3cm)not collapsing
         mild TR+,
         severe  MR+,
         trivialAR+,
         dilated all chambers ,
         global hypokinesia,
         severe LV dysfunction,
         mild PAHT,
         no MS/AS,no PE/LV clot

Diagnosis:
 - heart failure with reduced ejection fraction
 - dilated cardiomyopathy based on 2d echo findings
 - due to myocarditis- infectious and non- infectious (alcohol, toxins,allergens)
 - h/o fever with chills: suggestive of infectious etiology
 - most common cause of infective myocarditis: viruses
 
     (source: https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2519249/&ved=2ahUKEwjl7PfSj9npAhV5yDgGHTfuDsAQFjAAegQIBRAC&usg=AOvVaw0LQswAH3p-sWb-5mxRDKVN&cshid=1590757593981)

Treatment:
 - ACE inhibitors
 - Beta blockers
 - Diuretics
 - Vasodilator
 Other measures:
  - Fluid restriction <1litre/day
  - Salt restriction <2gms/day
    
  

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