Right Ventricular Faliure with Pulmonary HTN

Medicine case

I am an intern in medicine I am sharing this  case as important terms of completion of my internship.

A 30 years old male patient who is Shepard by occupation presented to our op with bilateral pedal edema extending up to knee and also with dyspnea on exertion since 15 days and he also given the history of palpitations since 1 year .

Decresed urine output since 2 days.

Patient apparently asymptomatic 1 year back then he developed the palpitations which were persistent and ponding type  and get precipitated on exertion and relieved by taking rest, patient started to have dry cough without  any expecteration in last 15 days he first became brethless for walking for a short distance. He also reported in getting upstairs and walking from one day before coming to hospital

  He reported he never felt dyspnic before and never felt orthopnea or PND

 He has no H/o fatigue ,no H/o cyanosis or hemoptysis

 He has no H/o jaundice & no hesitency and frequency in micturation

Past history

 No history of similar complaints in the past

No H/o DM ,HTN,TB,Branchial asthma

Personal history

Appetite - decreased

Sleep - inadequate

Bowel & bladder movements - regular

No addictions

No known allergies

Family history

They reported no history of similar complaints in family

General examination

Patient is concious , coherent and cooperative 

Moderately built and moderately nourished

Pallor- absent 

Icterus-absent

Cyanosis - absent 

Clubbing - absent

Lymphadenopathy- absent

Edema- bilateral pitting type of pedal edema extending upto knee

He has undecended testis ( cryptorchidism) ,very less facial hair ,no axillary hair,less pubic hair belonging to tanner stage 4

Vitals

Temperature: afebrile

Pulse:. 124 beats /minute

Respiratory rate: 20 cycles/ min

Blood pressure: 120/70 mmHg examined on supine position

Cardiac examination:

-Visible pulsation over tricuspid and mitral areas 

-Apex beat felt over 5th intercostal space  with in mid clavicular line  which is forceful and well sustained

-Right ventricular heave is present

-jvp raised with prominent 'a' wave

-s1 and s2 were heard with prominent p2

Respiratory examination:

 

Bilateral air entry present  with normol vesicular breath sounds

 

Abdominal examination:

Abdomen is soft ,nontender, all quadrents are moving equally with respiration

No organomegaly ,bowel sounds are heard

CNS EXAMINATION

The patient is consious , coherent, cooperative, oriented to time ,place and person

HMF are intact 

Minimental score is 28

Patient is like high stepping gait 

Motor system examination:

                                  Right.                 Left

Bulk:UL.                    N.                        N

          LL.                    N.                        N

Tone:UL.                   N.                        N

           LL.                   N.                        N. 

power: UL: biceps.          :     4/5

                     Triceps.        :.    4/5

                     Deltoid.        :.    5/5

            Wrist flexors.       :     4/5 

             Wrist extensors. :.   4/5

       LL: glutius.                : 5/5

              Iliosoas.               :4/5

              Quadriceps.        :3/5

              Gastronemius.   : 4/5

Reflexes:

                                          RT.                   LT

  superficial.           

                Corneal.           P                     P

                Conjuctival.     P.                    P

                Abdominal.     P.                    P

                Cremastric.      P.                    P

                Plantor.            P.                    P

  Deep:

              Biceps.             +1.                    +1.  

              Triceps.            +1.                    +1 

             Supinator.         +1.                    +1

              Knee jerk.         +1.                    +1

             Ankle jerk.         +2.                    +2

             

 Sensory examination :

         Anterio lateral senses are intact on both sides

         Dorsal tract senses  are also intact 

         Tactile localisation is Normal

         Two point descrimination impaired on lower limbs

Cerebellum:finger nose test : rapid

                      Finger - finger test : rapid

                      Coordination: intact       

 Absent meningial signs

     

Skull and spine are normal   

Provisional diagnosis:

-Right ventricular failure with primary Pulmonary artery hypertension

-Hypogonadism (tanner stage 4)

-Lower limb proximal myopathy

-Oral candidiasis with poor oral hygiene 

- impaired glucose tolerence

Treatment given

Tab. Pantop 40 mg po/ OD

Inj. Lasix 20 mg iv/ BD

Inj. Thiamine 1amp. in 100 ml NS

Inj. Optineurin 1amp in 100 ml NS

Tab sildenafil 10mg po OD

Tab benformet plus od

On diuretic therapy and vaso dilator therapy patient got better and discharged in stable condition

Advice at discharge

Fluid (1.5 to 2 L/day) and salt (2 gm /day) restriction

Tab sildenafil 10 mg po/bd

Tab benformet po/OD for 2 weeks

Chlorhexidine oral gargles for two weeks

Oral candid paint

Diet according to Harvard plate 

Work up for FSH,LH,GNRH

Review after 2 weeks

Thyroid profile

Thyroid profile

CUE

LFT

RFT

2D ECHO

E

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