Breathlessness on Exertion
Patient’s Problem
A 56-year-old male, Mr. Shivam (name changed to protect identity), an office manager with hypertension and dyslipidemia, came in with a three-month history of progressive breathlessness. What started as mild difficulty while climbing stairs had turned into shortness of breath after walking just 50–100 meters. He had no fever, cough, wheezing, palpitations, or recent infection. Given his risk factors and worsening symptoms, he consulted an experienced general physician in Vadodara at Shivaay Hospicare.
Diagnosis
Based on his symptoms and clinical examination, the doctor diagnosed early heart failure with reduced ejection fraction (HFrEF), likely linked to long-standing hypertension and possible underlying ischemic heart disease.
Key findings included:
Physical Exam:
- S3 gallop
- Mild ankle edema
- Mild jugular venous distention
- Bibasilar crackles on lung exam
Lab Tests:
- BNP: 412 pg/mL (elevated, suggestive of heart failure)
- Hemoglobin normal
- Troponin normal
- The lipid profile showed elevated LDL
ECG: Left ventricular hypertrophy pattern, no acute ischemic changes.
Chest X-ray: Cardiomegaly with mild pulmonary congestion.
Echocardiogram: Ejection fraction 40%, mild LV hypertrophy, Grade I diastolic dysfunction.
These findings confirmed the diagnosis and guided the treatment plan set by the attending specialist. Patients with such symptoms are often advised to consult a qualified lady doctor in Vadodara or women’s general surgeon when structural or cardiac-related complications are suspected.
Treatment
Mr. Shivam was started on guideline-directed therapy for heart failure.
Medications:
- ACE inhibitor or ARB
- Beta-blocker
- Diuretic for congestion
- Spironolactone
- SGLT2 inhibitor
Ongoing Care:
- Low-sodium diet
- Light daily activity as tolerated
- Weight and fluid monitoring
- Smoking cessation
Additional Evaluation:
A stress test or cardiac CT angiography was suggested to assess possible coronary artery disease.
Result
His outlook is good with timely treatment. At follow-up, his breathlessness improved, walking capacity increased, and blood pressure came under better control. If ignored, conditions like early heart failure can progress to severe fluid overload, arrhythmias, or hospitalization. Early evaluation by an experienced general physician in Vadodara helps prevent these complications.
Note: This case study is for illustrative purposes only and should not replace professional medical advice. If you have concerns about your health, please consult with a qualified healthcare provider.
