G Kusuma
58
Studying Final year part 2 ....
I was given a case of 35 year male and details were given in the following link
https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1
which lead to all the other symptoms and heart failure
Refrence from
58
Studying Final year part 2 ....
I was given a case of 35 year male and details were given in the following link
https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1
Cheif complaints
Asymptotic 1 month back than developed fever of high grade
Associated with chills
Causes:
- Bacterial
- Parasitic
- Viral
Antimalaria medication was given but fever subsided spontaneously and characteristic of high grade indicating...... most propably viral cause ....
2. Pedal edema
Bilateral , pitting type
Causes
- Cardiac failure
- Liver failure
- Renal failure
- Drug causes
- Dvt
I conclude cause for edema to CARDIAC causes since history
doesn’t support dvt
Drug causes since no history related to drug usage
Renal causes since no periorbital edema or oliguria seen
Liver causes since no bilirubin variation or ascitis seen
3. Dyspnea
Initally NYHA classification 3
On medication decreased to class 2
Paroxymal nocturnal dyspnea
Why dyspnea ..????
What exactly happened to his heart???
Examination findings
Genreal examination show normal finding
CNS : intact
Motor system normal
Sensory system normal
No cerebral signs
Cvs : s1 s2 heard normal
Early inspiratory crepts heard which make diagnosis confined to heart
Jvp raised elevated a wave indicating Tricuspid regurgitation
USG : shows moderate pleural effusion with ascites
Grade 1 fatty liver
2D ECHO:EF-27%
IVC dilated(2.3cm)not collapsing. Due to dialation of ivc blood back flow
mild TR+ Due to valvular dysfunction
severe MR+ Due to valvular dysfunction
trivial AR+ Due to valvular dysfunction
dilated all chambers
global hypokinesia. Due to cardiomegaly
severe LV dysfunction due to valvular dysfunction
mild PAHT
no MS/AS
no PE/LV clot
What happened to valves ??
Case history shows valvular dysfunction
👇🏻👇🏻
which is the reason for obstruction
👇🏻👇🏻
Heart load increases
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Remodeling of heart tissue leads to cardiomegaly
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Leads to regurgitaion of blood to IVC , Pulmonary veins
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Ivc regurgitation leads to portal hypertension liver dysfunction
Backward flow of blood to lungs lead to acumulation of fluids and dyspnea
👇🏻👇🏻
Heart failure
What lead to valvular dysfunction..?
In my interpretation valvular dysfunction in my case might be due to viral fever mostly coxsackie virus which mimics molecular resembles heart molecules and cause MYOCARDITISwhich lead to all the other symptoms and heart failure
Provisional diagnosis : heart failure with reduced ejection fraction secondary to viral myocarditis or inflammatory myocarditis
Further investigations i suggest
Cardiac catheterization and endomyocardial biopsy. A small tube (catheter) is inserted into a vein in your leg or neck and threaded into your heart. In some cases, doctors use a special instrument to remove a tiny sample of heart muscle tissue (biopsy) for analysis in the lab to check for inflammation or infection.
Treatment
In many cases, myocarditis improves on its own or with treatment, leading to a complete recovery. Myocarditis treatment focuses on the cause and the symptoms, such as heart failure.
In mild cases, persons should avoid competitive sports for at least three to six months. Rest and medication to help your body fight off the infection causing myocarditis might be all you need. Although antiviral medications are available, they haven't proved effective in the treatment of most cases of myocarditis.
Certain rare types of viral myocarditis, such as giant cell and eosinophilic myocarditis, respond to corticosteroids or other medications to suppress your immune system. In some cases caused by chronic illnesses, such as lupus, treatment is directed at the underlying disease.
Drugs to help your heart
If myocarditis is causing heart failure or arrhythmias, your doctor might hospitalize you and prescribe drugs or other treatments. For certain abnormal heart rhythms or severe heart failure, you may be given medications to reduce the risk of blood clots forming in your heart.
If your heart is weak, your doctor might prescribe medications to reduce your heart's workload or help you eliminate excess fluid, including:
Angiotensin-converting enzyme (ACE) inhibitors. These medications, such as enalapril (Vasotec), captopril (Capoten), lisinopril (Zestril, Prinivil) and ramipril (Altace), relax the blood vessels in your heart and help blood flow more easily.
Angiotensin II receptor blockers (ARBs). These medications, such as losartan (Cozaar) and valsartan (Diovan), relax the blood vessels in your heart and help blood flow more easily.
Beta blockers. Beta blockers, such as metoprolol (Lopressor, Toprol-XL), bisoprolol and carvedilol (Coreg), work in multiple ways to treat heart failure and help control arrhythmias.
Diuretics. These medications, such as furosemide (Lasix), relieve sodium and fluid retention.
Treating severe cases
In some severe cases of myocarditis, aggressive treatment might include:
Intravenous (IV) medications. These might improve the heart-pumping function more quickly.
Ventricular assist devices. Ventricular assist devices (VADs) are mechanical pumps that help pump blood from the lower chambers of your heart (the ventricles) to the rest of your body. VADs are used in people who have weakened hearts or heart failure. This treatment may be used to allow the heart to recover or while waiting for other treatments, such as a heart transplant.
Intra-aortic balloon pump. Doctors insert a thin tube (catheter) in a blood vessel in your leg and guide it to your heart using X-ray imaging. Doctors place a balloon attached to the end of the catheter in the main artery leading out to the body from the heart (aorta). As the balloon inflates and deflates, it helps to increase blood flow and decrease the workload on the heart.
Extracorporeal membrane oxygenation (ECMO). With severe heart failure, this device can provide oxygen to the body. When blood is removed from the body, it passes through a special membrane in the ECMO machine that removes carbon dioxide and adds oxygen to the blood. The newly oxygenated blood is then returned to the body.
The ECMO machine takes over the work of the heart. This treatment may be used to allow the heart to recover or while waiting for other treatments, such as a heart transplant.
In the most severe cases, doctors might consider urgent heart transplantation.
Some people might have chronic and irreversible damage to the heart muscle requiring lifelong medications, while other people need medications for just a few months and then recover completely. Either way, your doctor is likely to recommend regular follow-up appointments, including tests to evaluate your condition.
Refrence from
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