Heart failure
Case of SOB and bilateral pedal edema
The following case was given to us where the patients presented with SOB and pedal edema to understand the way the symptoms present in cases of heart disorders.
We will now try and analyse the following case:
The provisional diagnosis of this patient was given as "heart failure with reduced ejection fraction secondary to viral myocarditis."
The patient presented with,
- H/O high grade fever with chills, and had taken antimalarials as prescribed by a local RMP a month ago. he recovered.
- H/O bilateral pitting type of pedal edema up to the knees since 2 weeks
- H/O SOB which was progressive, initially NYHA III now NYHA II since 2 weeks
- H/O PND, generalised weakness from 2 weeks
On examination and investigations the following were found:
- raised JVP
- right ISA early inspiratory crepts
- rt moderate pleural effusion
- mild ascites
- EF= 27%
- severe MR
- global hypokinesia
- dilated chambers
- severe LV dysfunction
In this case,
- the patient has a H/O infection which was found out to be viral myocarditis, which is an inflammatory condition of the myocardium causing the muscle to become weak
- the patient also has severe mitral regurgitation.
- mitral regurgitation is a condition where the mitral valves allow retrograde flow of blood into the left atrium during the left ventricular contraction.
- as there is less blood flowing into the aorta due to regurgitation of blood into the atrium, the cardiac output is decreased, thereby causing weakness.
- also the viral myocarditis has weakened the myocardium thereby reducing the contractility of myocardium
- due to increased workload, that is preload (https://www.uofmhealth.org/health-library/aa86963), on the heart to pump enough blood to the body, mediated by the SNS and the RAAS, LV failure leads to LV dyfunction and structural changes as in the dilatation of chambers. https://en.m.wikipedia.org/wiki/Heart_failure
- in this case the MR could be a result of the viral myocarditis where dilated cardiomyopathy is common, due to stretching of the annulus
- blood regurgitates into the left atrium and lungs causing pulmonary congestion and right heart failure which is the reason for the edema, raised JVP (pulmonary hypertension) and SOB.
Questions that arise in this case
- what was the reason for the antimalarials to prescribe and work in this patient ?
- is his denovo DM a reason for his symptoms or an augmenting factor in his condition?
References:
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