What would the diagnosis be??

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G. Saahithya Reddy 

Roll no -141.

I've been given this case to solve in an attempt to understand the complete patient's clinical data analysis to develop my competency in reading ,comprehending clinical data that includes history, investigations ,coming to a diagnosis and treatment to be given.
The  entire patients history can be found in the link given here below:https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1.
The main problems of the patient are-

• Shortness of breath since 2 weeks
• Pedal edema since 2 weeks
• Fatigue since 2 weeks

PEDAL EDEMA:
It can arise from either cardiac pathology, renal pathology or hepatic pathology.
The patient complains of bilateral pedal edema so the differentials are:
Congestive heart failure 
Chronic liver disease 
Chronic kidney disese
Anemia
Drugs
Since hemoglobin is 15.2g/dl which is in the normal range and no evidence of pallor we can rule out anemia.
The patient doesn't give any history of oliguria ,facial puffiness  we can rule out chronic kidney disease.
The patient complains of other associated features like shortness of breath, on examination JVP is raised, so we can suspect cardiac pathology.
The patients albumin count is normal,no icterus but on examination there's ascites so there might or might not be a liver pathology.
There's no history of drug usage so it can be ruled out.
So by the above information we can suspect cardiac pathology. 
Shortness of breath :
The  patient's complains of shortness of breath since 2 weeks NYHA grade 3 i. e marked limitation in activity.
The  differentials for this cause are:
Cardiac pathology 
Respiratory system
Renal pathology 
Metabolic disturbances
Anemia
Neuromuscular junction disorders
Anemia
The patient doesn't have any pallor and has normal hemoglobin count so anemia is ruled out
The patient has no hematuria, facial puffiness so renal pathology is ruled out.
There's no history of cough,  wheeze, fever so we can rule out respiratory cause.
He has no ptosis and no associated nmj symptoms.
He's not diabetic.
The  patient has associated PND ( paroxysmal nocturnal dyspnea) hence we strongly suspect cardiac pathology
Fatigue :
The patient complains of fatigue since 2 weeks. The  differentials could be :
Heart disease 
Lung disease 
Diabetes
Anemia 
Thyroid conditions
Of which the associated symptoms are suggestive of cardiac pathology.

What is the  anatomical location of the  above disease? 
It  is the heart where the  exact pathology is.
What is the probable etiology and pathology of the  disease? 
The  symptoms such as dyspnea,  paroxysmal nocturnal dyspnea,  pedal edema point towards heart failure.

• Presence of inspiratory crepitations at the  base of lungs suggest left heart failure. 
• Presence of raised JVP is suggestive of right heart failure. 

The  most common cause  of right heart failure is left heart failure.
PND mechanism is :
During sleep there's redistribution of peripheral fluid into central circulation and this takes around 2-4 hours after sleeping so patient generally manifests in the middle of the sleep.

Now we need to find if it is reduced ejection fraction or preserved ejection fraction?
For this we must do 2D -Echocardiography.
The results are :

• EF -27%
• Ivc dilated not collapsing
• Severe mitral regurgitation
• Trivial aortic regurgitation
• Mild tricuspid regurgitatiom
• All chambers dilated
• Global hypokinesia
• Severe LV dysfunction 
• No MS/AS
• No pulmonary embolism, LV clots
• Mild pulmonary artery hypertension 

So since there the ejection fraction is 27% it is HFref.

What is the cause of HFref?? 
Why did the patient have fever with chills??? 

Investigations to be done:

Nt-pro BNP levels
Coronary angiogram
MRI
Myocardial biopsy
Immunohistochemistry
Treatment :

Non-pharmacological:
Education about the disease
Diet changes (avoidance of salt foods)
Eliminate alcohol consumption
Regular exercise
Pharmacological :
Diuretic therapy
ACE inhibitors
ARB blockers
Beta blockers
Vasodilator therapy
Implantable cardiac defribillators
Coronary revascularisation
Heart transplantation
Vascular assisted devices. 

But how do we find :
What is the cause for reduced ejection heart failure?? 
What is the cause for fever with chills??