A 35yr old gentleman complaining of shortness of breath and pedal edema

A35year male presented with complaints of shortness of breath since 2weeks and pedal Edema since 2weeks

History of presenting illness

Patient was apparently asymptomatic 1month back then he developed fever ,associated with chills ,which is high grade for which he took treatment at local rmp where he was given anti malarial drugs and treated symptomatically after which patient felt better.

-Currently from 2weeks he is complaining of b/l pedal edema ,extending up to knees ,pitting type,progressing in nature shortness of breath from 2weeks ,initially NYHA 3 after treatment

- Now grade 2 h/o paroxysmal nocturnal dyspnea and generalised weakness from 2weeks

- No h/o fever ,vomitings ,abdominal distension ,diarrhoea ,cough,cold

PAST HISTORY :

No history of similar complaints in the past

Not a known case of DM ,HTN,Epilepsy,CVA,CAD

PERSONAL HISTORY :

mixed diet with normal appetite and normal bowel&bladder habits

H/o alcohol and smoking occasionally

No significant family history

GENERAL EXAMINATION:

well built and well nourished

Afebrile

Pallor absent

Noicterus,cyanosis,clubbing,lymphadenopathy

Edema upto knees (grade2)

BP:130/80mmhg

PR:80bpm

CVS:s1s2heard

RS:right ISA early inspiratory crepts +

P/A:soft and non tender

CNS:Hmf normal

Cranial nerves intact

Motor system normal

Sensory system normal

No cerebellar signs

JVP of this patient

https://drive.google.com/file/d/1Gr2xuU5bcPUbNmQaPjVIavwn1m-FK7gr/view?usp=drivesdk



INVESTIGATIONS:

Heamoglobin :15.2

Tlc:9600

Platelet:2.39

FBS:102

PLBS:205

Total cholesterol:150

Triglycerides:87

Hal:33

LDL:72

Vldl:17.4

Urea:24

Creatinine:0.8

Uric acid :6

USG abdomen:right moderate pleural effusion ,grade1 fatty liver,mild ascites

2D ECHO:EF-27%,IVC dilated(2.3cm)not collapsing,mild TR+,severe MR+,trivial AR+,dilated all chambers ,global hypokinesia,severe LV dysfunction,mild PAHT,no MS/AS,no PE/LV clot

DIAGNOSIS: heart failure with reduced ejection fraction secondary to viral myocarditis with denovo DM type 2

TREATMENT:

Tab.lasix 80mg...40mg...40mg

Tab.isosorbide mononitrate10mg bd

Tab.hydralazine 25mg

Tab. Telma20mg

Tab.metformin 500mg po od

Fluid restriction <1litre/day

Salt restriction <2gms/day

On 14/5/2020

Patient came for opd with complaints of pedal odema and shortness of breath  since 1week 

Patient is investigated for 2d echo and findings are: left ventricular dilatation ,left atrial dilatation,end point septal separation distance is increased,right atrial and ventricular dilatation ,global hypokinesia

Based on the above findings we have increased the dosage of vymarda 50mg BD  (sacubitril 26mg +valsartan24mg) to vymarda to 100 mg BD 

PROCEDURE:

I have seen the 2D ECHO of this patient today 

https://drive.google.com/file/d/1K9Fk66l6c79ziOF-dIYQ3vDlGbSavlr7/view?usp=drivesdk

NEET TOPIC :

Myaesthenia gravis:

It is a neuromuscular diseases that lead to varying degrees to skeletal muscle weakness.

Pathophysiology:

T cell and B cell mediated activation leads to production of antibodies which causes

a)Decrease in number of acetylcholine receptors in the post synaptic membrane

b)acetylcholine cannot bind to receptors

Antibodies : such as

1)anti acetylcholine receptor antibody

2)anti musk antibody

Presenting complaints:

Starts with ocular weakness or pharyngeal weakness followed by generalised weakness (mainly proximal muscles of lower limb)

Management :

Investigations:

1)ice pack test

2)tensilon test

3)repetitive nerve stimulation tests

4)single nerve fibre electromyography

Treatment:

a)pyridostigmine:30-60mg 6th hourly later taper off

Relapse- steroid +azathioprine

Crisis- IvIg and plasma exchange

b) thymectomy.