A case of acute Left Ventricular Failure (LVF) precipitated by LRTI. The patient is a 55-year-old male presenting to Emergency and Accidents, Benazir Bhutto Hospital with acute onset shortness of breath on doing ordinary activities. Symptoms began 3 days ago before and had progressively worsened with aggravation on lying flat and relieved by sitting. He also wakes up from sleep feeling breathless.He have productive cough with whitish colored sputum. He also reports of fever which is undocumented, gradual in onset, relieved by taking paracetamol. Differential Diagnosis • Lower Respiratory Tract Infection (Bronchitis, bacterial pneumonia, COVID, viral pneumonia) • Heart Failure with preserved ejection fraction • Congestive Heart Failure • Acute infective exacerbation of COPD

1. Case of 55 year old male
presenting with
shortness of breath
Dr. Khubaib Samdani
Department of Cardiology,
Benazir Bhutto Hospital
Houseofficer Dec 2022 - March 2023

2. History
The patient is a 55-year-old male presenting to Emergency
and Accidents, Benazir Bhutto Hospital with acute onset
shortness of breath on doing ordinary activities.
Symptoms began 3 days ago before and had progressively
worsened with aggravation on lying flat and relieved by
sitting. He also wakes up from sleep feeling breathless.

3. He have productive cough with whitish colored sputum.
He also reports of fever which is undocumented, gradual in
onset, relieved by taking paracetamol.
He denies chest pain, palpitations, pressure, abdominal
pain, abdominal dissension, nausea, vomiting, and
diarrhea.

4. There are no known ill contacts at home. His family
history includes significant heart diseases,
hypertension and diabetes. Social history is positive
for smoking tobacco use at 25 pack years. He quit
smoking 10 years ago due to increasing shortness of
breath. He had been consumer of naswar for 20 years
which he quit 2 months ago. He denies all alcohol and
other illegal drug use. There are no known foods,
drugs, or environmental allergies.

5. Past medical history is significant for dilated
cardiomyopathy, COPD, diabetes mellitus, tobacco
usage and hepatitis C. He was admitted in CCU on 1st
January, 2023.
Past surgical history is insignificant.

6. Initial physical exam reveals temperature 97.3 F, heart rate
82 bpm, respiratory rate 24, BP 90/60 mmHg and O2
saturation 90% on room air.
Lean acutely ill-appearing male. Well-developed and well-
nourished with cannula in right hand. Lying on a hospital
stretcher under one blanket.
Physical Examination
Constitutional

7. Normal rate, irregular rhythm, and normal heart sound (S1 and S2) with
holosystolic murmur. 2+ pitting edema bilateral lower extremities and
strong pulses in all four extremities. JVP is raised.
Pulmonary/Chest: B/L fine basal crackles, (+) expiratory wheezing noted,
bilateral rhonchi, breath sounds decreased (decreased air entry)
Abdominal, skin, neurological exam is unremarkable.
Cardiovascular
Respiratory

8. Differential Diagnosis
• Lower Respiratory Tract Infection (Bronchitis,
bacterial pneumonia, COVID, viral pneumonia)
• Heart Failure with preserved ejection fraction
• Congestive Heart Failure
• Acute infective exacerbation of COPD

9. Initial evaluation to elucidate the source of dyspnea was
performed and included CBC to establish if an infectious
or anemic source was present, S/E and RFTs to review
electrolyte balance and review renal function, ECG, and
chest x-ray. Considering that it is winter, a rapid influenza
assay should be obtained as well.
Initial Evaluation

10. CBC:
LFTs:
RFTs:
Mildly increased neutrophils (81.2%) and decreased
lymphocytes (12.3%). Hemoglobin is normal (13.6g/dL)
Mild elevation of ALT and AST which could be due to
liver congestion from overload.
Sr Urea is 68.76 and Sr Creatinine is 1.2

11. Right Axis Deviation. Irregularly irregular rhythm seen. Absent P
wave. No significant ST segment changes. T-wave inversion in
V6.
Gross enlargement of cardiac shadow seen with CTR= 16/20= 0.8
Suggestiveof global cardiomegaly with downward displacement
of diaphragm qith spare opacifications seen in B/L parahilar
region and lower zones. Radiologist Impression: These findings
are suggestive of pulmonary edema and acute infective etiology.
ECG:
Chest X-Ray:

12. ECG Credits: Fazal Sahab

14. 2D- Echo
• Severely dilated LA,
Lv
• Global hypokinesia
• Mild-moderate MR, TR
• No clots/PE seen

15. Acute LVF secondary to Dilated Cardiomyopathy
precipitated by LRTI
Final Diagnosis

16. Treatment

17. Further
Plan
Pulmonary Function
Tests