45yr male with Heart failure

July 20, 2020
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Case:
A 45 y old male upasarpanch by occupation and resident of nalgonda came to the hospital with the chief complaints of
Pedal edema since 15 days
Difficulty in walking since 15 days
Sob since 5 days

HOPI
Patient was apparently asymptomatic 15 days back then he developed bilateral pedal edema which is of pitting type intially upto ankle later progressed to knees 
Difficulty in walking since 15 days as patient felt heaviness in both the legs and felt difficulty to lift the legs from the ground
H/o of difficulty in holding and wearing chappals due to swelling of the both feet
Sob since 5 days grade 1-2 NYHA which is gradual in onset and progressive in nature, not associated with chest pain, and sweating
No h/o of PND, ORTHOPNEA, PALPITATIONS
NO h/o of dry cough, fever
No h/o of decreased urine output, facial puffiness,
No h/o distension of abdomen, no h/o jaundice
No h/o fatigue, 
No h/o hemoptysis


Past history:
no h/o similar complaints in past
not a known case of DM/HTN/CAD

personal history:
mixed diet with normal appetite and normal bowel/bladder movements
h/o alcohol since 10y daily
No h/o smoking
no significant family history.

General examination:
Thin  built; moderately nourished
Weight 69 kg to 61 kgs
Height 172 cms
BMI 
Arm span 192 cms
Ratio >1
Upper segment 74 cms
Lower segment 98 cms
Thumb sign and wrist sign +ve
mild pectus excavatum 
Stretch marks on the knees +
B/L pedal edema 

Pallor absent 
Icterus negative
No cyanosis,clubbing,lymphademopathy,Edema.
no short neck
no scars;no h/o tropic ulcers
Vitals 
Bp 120/60 mmhg
Pr 80 bpm regular

CVS
 Inspection :
  Chest is symmetrical but mild pectus excavatum present

     ●  No precordial bulge. 
        Trachea appears to be central

     ● Apical impulse – 6th Intercostal space lateral to mid clavicular line
     ● visible scars- no scar present 
     ●  no engorged superficial veins

PALPATION:
Mitral area-
           APEX BEAT-1.site- 6 the  Intercostal space lateral to  mid clavicular line 

Pulmonary area-
           No Palpable P2
          No PALPABLE HEART SOUNDS
          No  THRILL
Aortic area-
           No PULSATIONS-
           No PALPABLE HEART SOUNDS
            No THRILL
Tricuspid area-
         No PULSATIONS
          No   PALPABLE HEART SOUNDS
          No THRILL
Epigastric pulsations-absent 
No Thrill in carotid arteries
No Suprasternal pulsations
No Palpable pericardial rub-

AUSCULTATION;  
Mitral area 
S1: loud
S2:  Normal
Splitting: 
Murmer:
S3,S4 absent
RS:
 BAE +, NVBS
P/A:
 soft ,nontender 
No hepatomegaly, no splenomegaly
CNS
  HMF- patient conscious
        oriented to place/time/person
no h/o aphsia/dysarthria
no h/o dysphonia
no h/o memory loss
no h/o emotional lability
MMSE- 30
cranial nerves- intact
MOTOR SYSTEM 
                                              Right.         Left
Bulk:    inspection                 N.               N
             palpation.                 N.              N
                                 
Tone:               ul.            normal.         Normal
                         LL.         N.                     N
Power              5/5 all 4 limbs
Reflexes.  
   Superficial reflexes
                       Right.           Left
Corneal.            P                  P
Conjunctival    P.                  P
Abdominal.      -               -
Plantar            Flexor         Flexor


    Deep tendon reflexes 
                     Right.             Left
Biceps.          -                   ---
Triceps.         ---.                   ---
Supinator.     ---                    ---
Knee              ---                    ---
Ankle.            ---                    ---
 
SENSORY SYSTEM 
                                    RIGHT.           LEFT
SPINOTHALAMIC 
             crude touch.   N.                   N
                 pain.             N.                   N
            temperature.   N.                   N
post:
             fine touch.      N.                   N
             vibration.        N.                   N
     position sensor.    N.                   N
 cortical 
 2 point discrimination  N.                   N
tactile localisation.        N.                   N

CEREBELLUM
titubation - absent
ataxia - absent
hypotonia. Absent

Investigations:
Ultrasound, 2D echo, chest x-ray, LFT, CUE, serum creatinine, serum urea



Diagnosis:
Right Heart failure with preserved ejection fraction with ? Marfan's syndrome

Treatment:
Inj. Lasix 40mg IV TID
Tab. Spironolactone 50mg OD
Tab. Aspirin 75mg PO OD
Tab. Clopidogrel 75mg PO OD
Tab. Rosuvostatin 40mg OD HS
Salt restricted diet
Fluid restriction <1.5L/day
Tab. Pantop 40mg OD
Daily weight measurements
Tab. MVT PO OD
Tab. Benfothiamine PO OD

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