SHORTNESS OF BREATH
I've been given these three cases data here (http://medicinedepartment.blogspot.com/2020/05/re-case-based-online-learning.html) in an attempt to understand about Shortness of Breath.
In case 1, https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1
The complaints of the patient are :
- Shortness of Breath since 2 weeks - Paroxysmal nocturnal dyspnea.
- Bilateral pedal edema since 2 weeks extending up to knee, pitting type.
- Generalised weakness since 2 weeks
- H/O Fever 1 month back
1. When a patient presents with breathlessness the ethology can be arising from either Respiratory system, Cardiovascular system or Neuromuscular system.
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| (http://unmfm.pbworks.com/f/approach%20to%20dyspnea.pdf)
2. Shortness of breath associated with bilateral pedal edema is usually associated with heart failure.
The pathophysiology of edema in heart failure is as follows
Heart failure causes back up blood to accumulate in pulmonary veins and cause pulmonary edema - Leading to SOB.
3. The fever which occured a month back suggests an infective cause.
On examination,
Inspirations crept - might suggest pulmonary edema
Mild ascites was found on ultrasound because of increased water retention found on ultrasound.
Ultrasound even showed plural effusion.
JVP was raised - Indicating right heart failure.
2D echo was done and there was a reduced ejection fraction.
Reduced ejection fraction may be suggestive of Myocarditis, cardiomyopathy or coronary artery disease leading too heart failure.
Dilated heart chambers were found - Dilated cardiomyopathy. The dilatation of heart chambers led to Mitral regurgitation and Tricuspid regurgitation as found on echo. The viral infections that inflame the heart muscle is the main cause of dilated cardiomyopathy. The other causes of dilated cardiomyopathy are Coronary heart disease, high blood pressure, diabetes, Alcohol when associated with poop diet, certain toxins and Drugs. (https://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults/dilated-cardiomyopathy-dcm) The other causes were ruled out and a diagnosis of HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO VIRAL MYOCARDITIS was made. Treatment : Furosemide - LASIX a loop diuretic to reduce edema. Loop diuretics, reversibly, inhibit the Na+⁄2Cl-⁄K+ co-transporter of the thick ascending loop of Henle where one-third of filtered sodium is reabsorbed. This causes decreased sodium and chloride reabsorption and increased diuresis. ISOSORBIDE MONONITRATE - A vasodilator HYDRALAZINE - Peripheral vasodilator Telmisartan - TELMA an angiotensin receptor blocker. Restricted water and salt intake to prevent fluid overload. ———————————————————————————————————————————————————— In case 2, (https://himabindu5.blogspot.com/2020/05/hello-everyone.html)
The complaints of the patient are,
On palpation,
The apex beat changed downward outward (6th inter coastal space in anterior ancillary line) - suggestive of LV enlargement
Auscultatory findings were suggestive of mitral stenosis.
Lous S1 was heard in the mitral area - In mitral stenosis the first heart sound is accentuated because of a wide closing excursion of the mitral leaflets
Splitting of S2 in pulmonary area with loud P2 component - may be because of pulmonary hypertension because of mitral stenosis.
ECG was done and there was an irregular rhythm with absent P waves, Right axis deviation, ST elevation in V4 V5 aVR.
Chest X-ray showed cardiomegaly of Right atrium, Right ventricle, Left ventricle.
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2D echo showed calcified mitral valves with a characteristic hockey stick appearance on the anterior valve.
Fish mouth appearance
The elevated bilirubin and other liver enzymes is suggestive of liver dysfunction may be because of hypoperfusion because of reduced cardiac output.
Same might be the reason for abnormal RFT.
Based on these, a diagnosis of MITRAL STENOSIS WITH HEART FAILURE was made.
Treatment :
Amiodarone for irregular heart beat.
LASIX - furosemide a loop diuretic
Aspirin - ECOSPRIN for its antiplatelet action.
Fluid and salt restriction just like the previous patient.
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In case 3, https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1
The complaints of the patient are
Right ventricular heave is present
Visible pulsation over tricuspid and mitral areas
JVP raised with prominent 'a' wave
These are the classical signs of pulmonary hypertension.
ECG showed P mitrale in V1 - indicative of left atrial enlargement
Inverted T waves
Chest X-ray showed
Enlarged right atrium
Prominent pulmonary outflow tract
2D echo was done and it showed
Dilated left atrium and ventricle
Mild dilatation of IVC
The patient had a high stepping gait - but the patient isn’t aware of the change in gait which suggests he had it since childhood.
Power of both the limbs is slightly reduced.
Two point discrimination is impaired.
Suggestive of a congenital neuromuscular problem.
Because of this lack of body and facial hair and scanty pubic hair an ultrasound of scrotum was done to find empty scrotal sacs bilaterally.
He belonged to tanner stage 4.
This only must have been the reason for subnormal muscle mass.
A diagnosis of RIGHT VENTRICULAR FAILURE WITH PULMONARY ARTERY HYPERTENSION associated with HYPOGONADISM was made.
In this case the pulmonary artery hypertension might have been caused because of hypogonadism as testosterone which acts as vasodilator is not present in sufficient quantities. (https://pubmed.ncbi.nlm.nih.gov/16472172/)
Treatment:
LASIX - loop diuretic
SILDENAFIL - vasodilator
BENFOMET PLUS - for neuropathy
THIAMINE - supplement
OPTINEURIN - supplement
I would suggest a trial of testosterone therapy after GnRH, LH, FSH work up.
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| This is not a patient image (https://www.researchgate.net/figure/In-the-parasternal-long-axis-view-of-a-patient-with-severe-rheumatic-heart-disease-the_fig4_315865433) |
Fish mouth appearance
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| This is not a patient image (https://onlinelibrary.wiley.com/doi/pdf/10.1111/1754-9485.15_12785) |
Same might be the reason for abnormal RFT.
Based on these, a diagnosis of MITRAL STENOSIS WITH HEART FAILURE was made.
Treatment :
Amiodarone for irregular heart beat.
LASIX - furosemide a loop diuretic
Aspirin - ECOSPRIN for its antiplatelet action.
Fluid and salt restriction just like the previous patient.
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In case 3, https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1
The complaints of the patient are
- Bilateral pedal edema.
- Dyspnea on exertion since 15 days.
- Palpitations since 1 year which were persistent and ponding type, precipitated on exertion and relieved on rest.
- Decreased urine output since 2 days.
On examination,
Apex beat felt over 5th intercostal space with in mid clavicular line which is forceful and well sustained
Right ventricular heave is present
Visible pulsation over tricuspid and mitral areas
JVP raised with prominent 'a' wave
These are the classical signs of pulmonary hypertension.
ECG showed P mitrale in V1 - indicative of left atrial enlargement
Inverted T waves
Chest X-ray showed
Enlarged right atrium
Prominent pulmonary outflow tract
2D echo was done and it showed
Dilated left atrium and ventricle
Mild dilatation of IVC
The patient had a high stepping gait - but the patient isn’t aware of the change in gait which suggests he had it since childhood.
Power of both the limbs is slightly reduced.
Two point discrimination is impaired.
Suggestive of a congenital neuromuscular problem.
Because of this lack of body and facial hair and scanty pubic hair an ultrasound of scrotum was done to find empty scrotal sacs bilaterally.
He belonged to tanner stage 4.
This only must have been the reason for subnormal muscle mass.
A diagnosis of RIGHT VENTRICULAR FAILURE WITH PULMONARY ARTERY HYPERTENSION associated with HYPOGONADISM was made.
In this case the pulmonary artery hypertension might have been caused because of hypogonadism as testosterone which acts as vasodilator is not present in sufficient quantities. (https://pubmed.ncbi.nlm.nih.gov/16472172/)
Treatment:
LASIX - loop diuretic
SILDENAFIL - vasodilator
BENFOMET PLUS - for neuropathy
THIAMINE - supplement
OPTINEURIN - supplement
I would suggest a trial of testosterone therapy after GnRH, LH, FSH work up.
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