35 years man with a dilated heart
35 year old man working as a food caterer presented to our OPD with the chief complains of
Dyspnea at rest since 5 days
Cough with expectoration since 5 days
Bilateral pedal edema since 4 days
Abdominal distension since 3 days
Patient was born and brought up in *********. He was born to a farmer and a housewife. He has 2 elder siblings, his elder sister is married to an advocate and has 2 children and his elder brother is working as a software engineer. He pursued his degree in electronics but was not successful in finding a job in this branch, so he moved to another state 10 years back and started working in a food catering business along with his friends. During his stay outside his hometown, he says he used to often feel lonely and used to often consume whiskey along with his friends which got to a point that he started consuming around 180 ml of whiskey everyday. He also tells that he would occasionally smoke cigarette once in a while along with his friends. In those 10 years he never paid a visit to his hometown due to financial issues and decided not to get married anytime soon as he wanted to settle the financial issues his family was facing.
He was apparently alright until one morning in November 2019 when he had high fever with chills and visited a local hospital where he got admitted and was diagnosed with malaria for which he received treatment.
In Dec 2019 he says he started feeling breathless while climbing up the stairs which progressed over the next 5 days to such an extent that he even felt dyspneic even at rest and had dry cough on and off. He says that his dyspnea and cough aggravated on laying in bed. He gradually developed bilateral pedal edema followed by abdominal distension over the next few days which alarmed him and he decided to pay a visit to a doctor. He visited a local hospital and was put on some medications ( no documentation ) which patient couldn't recall of. Since it did not improve his symptoms he visited our hospital in January 2020.
His blood picture, renal and liver parameters were in within the normal range.
On routine investigations his HbA1c was found to be 8.4 %.
His Ultrasonography of abdomen revealed Grade 1 fatty liver ( probably secondary to his alcohol intake), mild ascites, Right moderate pleural effusion.
2DEcho was done which revealed that all the 4 chambers to be dilated with an ejection fraction of 27, global hypokinesia, severe MR, trivial AR, severe LV dysfunction with mild PAH, dilated IVC (2.3cm)
A diagnosis of HEART FAILURE WITH REDUCED EJECTION FRACTION
DENOVO TYPE 2 DM
and he was started on
Tab Lasix 80mg in the morning, 40mg in the afternoon and evening
Tab Isosorbide mononitrate 10mg twice a day
Tab Hydralazine 25mg
Tab Telma 40mg
Tab Metformin 500mg once a day
and was advised for fluid and salt restriction
He was advised for a coronary angiogram for which he visited Hyderabad. CAG was performed on 24th of January 2020 which turned out to be normal and he was started on Tab Vymada 50mg and Tab Met XL 12.5mg
( Sacubitril 26 mg and Valsartan 24 mg) along with Tab Ecosprin AV (75/20)
On regular at home monitoring of blood glucose levels which were within the normal range, he stopped taking Tab Metformin.
On 14th March 2020 he paid a visit to our hospital with the similar complains and a review scan of 2DEcho was done which revealed end point septal separation distance to be increased and Tab Vymada was increased to 100mg.
On July 28th, 2020 he presented to our OPD with the complains of Dyspnea at rest since 5 days which apparently aggravates when the patient is in supine posture and he also complains of occasional cough with scanty mucoid, non blood tinged sputum especially while he is asleep. He says he developed bilateral pedal edema extending upto his knee over the past 4 days followed by abdominal distension.
Patient appeares to have gained weight with abdominal girth measuring 116cm.
and he weighed 101 kg
Icterus was present
He weighs 93 kgs now
He appeared to be in respiratory distress with a respiratory rate of 28 cycles per minute and his saturation was at 98 % on room air.
His heart was beating at 120 bpm with a blood pressure of 100/70mmhg.
He was afebrile.
His JVP was raised
His apex beat was in 6th intercostal space, 1cm lateral to midclavicular line.
On auscultation, S1 S2 +
His lungs were clear on auscultation
His abdomen was soft to palpate and bowel sounds were heard.
His 2Decho showed dilated chambers with global hypokinesia, ejection fraction of 26 %, severe MR, mild TR, Trivial AR, mild pericardial effusion, mild PAH and IVC measuring 1.7 cms.
Hemogram:
Hb - 13 g/dl
TLC - 7000 cells/cumm
Platelet count - 2.28 L/cumm
Complete Urine Examination:
showed no albumin, sugars, RBCs
2-4 Pus & epithelial cells
Renal Function Test :
Urea - 53 mg/dl
Creatinine - 1.4 mg/dl
Uric Acid - 9 mg/dl
Calcium - 9.6 mg/dl
Phosphorus - 3.3 mg/dl
Sodium - 133 mEq/L
Potassium - 4 mEq/L
Chloride - 98 mEq/L
Liver Function Test:
Total Bilirubin - 4.60 mg/dl
Direct Bilirubin - 2.42 mg/dl
AST - 56 IU/L
ALT - 44 IU/L
ALP - 129 IU/L
Total Proteins - 6.2 gm/dl
Albumin - 3.9 gm/dl
The Patient is currently on fluid and salt restriction
Along with INJ LASIX 40MG TID
TAB VYMADA 100 MG BD
TAB VALSARTAN 80MG OD
TAB MET XL 12.5MG OD
TAB DYTOR PLUS 10/25 OD
Patient has come back after 1 month
with the complains of
Dyspnea since 2 days
Orthopnea since 2 days
Loss of appetite since 2 days
Dyspnea exaggerated on walking
Says he has been getting up from sleep because of shortness of breath which is being releaved on sitting posture
He also tells us he doesn't feel like eating since 2 days
No complains of cough, hemoptysis, chest pain or palpitations
Reduced pedal edema
Pallor +
Icterus +
RR - 20 cpm
PR - 78 bpm
Bp - 140/80
Cvs - S1,S2 +
Lungs - clear
We had a look at his 2DEcho
His RBS was 111 mg/dl
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