Here is a case review which will show the effects of obese individual who snores and wakes up in the night with history of so called sleep apnea. This is the case diagnosed and treated by us in our hospital, in fact the PFT and all could not be done due to untoward reasons, this was purely a clinical diagnosis.
CASE:
A sixty year old male came to ICCU with complains of generalized swelling and mild breathlessness since he has got generalized swelling, the duration of these complaints lasts from last 15 days, and retention of urine since one day.
Complete History:
15 days back patient was apparently alright when he noticed swelling of both the lower limbs to start with, gradual in onset and progressive in nature, of pitting type, this gradually progressed to involve the genitalia i.e. scrotal edema seen with difficulty in voiding urine since last one day, and also involved his abdomen i.e. he noticed distension of abdomen which was insidious and progressive and has progressed to the present sate in these 15 days, associated with this generalized edema all over the body patient is experiencing mild grade of breathlessness i.e. of NYHA classification Grade II, this complains of breathlessness patient had never in the past before, there are no aggravating and relieving factors for his breathlessness.
Patient gives history of cough since last one year, productive in nature, aggravating in supine position, and disturbing patient’s night sleep, producing scanty amount of sputum. Patient is a non smoker, non alcoholic, non tobacco chewer. Patient is living sedentary life style has no work, and has never worked in any industry or factories.
Patient had similar complaints of abdominal distension and pedal edema a year back for which he was consulted in some private hospital where he was diagnosed to be having cardiac problem but the details were not revealed before patient and his relatives.
Patient is not a known case of asthma, COPD, diabetes mellitus, hypertension, and no history was elicited in favor of tuberculosis in the past neither any history suggestive of any interstitial lung disease was elicited. Patient is not on any drugs like bronchodilators, antihypertensives etc.
No history was elicited in favor of any thyroid involvement in the past, and no history was elicited suggestive of IHD or CAD.
Retrospectively when history was elicited it was reviled that, patient was very obese in the past from a long time, and used to snore at night routinely, and always used to wake up at night due to shortness of breath atleast 2 or 3 times per night, and after sometime used to sleep again, this made his nights uncomfortable and sleepless, disturbing his sleep. Due to this patient used to be very lethargic, fatigued, and all the time in day used to sleep i.e. was suffering from day time somnolence. ( This history takes us away towards the syndrome called OBSTRUCTIVE SLEEP APNEA SYNDROME). From last couple of months patient has reduced his weight.
EXAMINATION:
General examination.
A sixty year old well built conscious oriented male patient.
Pallor. Present
Icterus. Absent
Cyanosis. Both central and peripheral cyanosis present.
Clubbing. Absent
Lymphnodes. Absent
Edema. Generalized edema noted with abdominal distension,edema of genitalia, and bilateral pitting type of edema.
Vitals.
Pulse: 60 beats per minute, regular, moderate volume pulse with normal character
Blood pressure: 96/70 on presentation and later after starting treatment maintained at 110-120/70- 80.
JVP: raised.
Peripheral pulses all felt with normal character and volume.
Saturation: 84% on presentation without oxygen. On starting oxygen therapy maintained on 94-96% .
Systemic Examination:
Cardiovascular examination:
Pulse: 60 beats per minute,regular,normal character, moderate volume.
JVP: Raised.
Periphral pulses all were normal in character and regular. No abnormality detected.
Blood pressure: 96/70 on presentation, improved with treatment and maintained on 110-120/70-80.
Apex beat was noted to be shifted laterally outwards in 6th intercostal space, which was confirmed by palpation.
No pulsations were noted on precordium.
Apex beat of ill sustained nature without any thrill.
A systolic thrill felt in tricuspid area.
Palpable P2 was noted.
Chest wall appeared to be thick.
No obliteration of superficial cardiac dullness, was felt in 3rd intercostals space.
Auscultation revealed,
Soft S1 in mitral area with no regurgitant or stenotic murmur.
Pansystolic mumur in tricuspid area,harsh in nature, conducting to all over the precordium, even to the carotids.
No split of heart sounds and no gallops.
Loud P2 in pulmonary area, with conducted PSM of tricuspid regurgitation, and another mumur of severe intensity was heard i.e. an Ejection Systolic Murmur (ESM).
Conducted murmur of tricuspid regurgitation noted in aortic area with conduction even to the carotids. No signs suggestive of Aortic regurgitation and aortic stenosis were noted.

Respiratory System:
Bilateral air entry was equally noted in all lung fields bilaterally.
The only positive finding noted here was bilateral basal rales, with central and peripheral cyanosis.

Per Abdomen:
Abdomen is grossly distended, firm in consistency through out, with engorged veins over the abdomen, and slight tenderness in the right hypochondriac area.
Hepatomagaly present but could not be felt accurately due to tense abdomen.
Hernial orfices intact, edema noted over scrotum with difficulty in voiding urine.

Central Nervous System:
Clinically no neurodeficit noted.
INVESTIGATIONS:
Routine blood parameters were in normal range.
Serum creatinine and Blood urea in normal range.
Chest X- Ray showed Cardiomegaly s/o biventricular hypertrophy with more of right ventricular hypertrophy. No findings s/o COPD in CXR were noted.
ECG: RVH with First degree heart block.
DIAGNOSIS:
With history given by the patient it made us to think in line of involvement of heart as principal organ, it made us to go inline with right ventricular failure, considering the history and signs, but the exact cause was not revealed so that the diagnosis would be confirmed. But when the retrospective history was taken into account of obesity,snoaring,sleep apnea, it made us to think in the direction of so called the OBSTRUCTIVE SLEEP APNEA SYNDROME. With this we came to a specific diagnosis with a specific cause though rare but one of the major cause, and the case was diagnosed to be,
OBSTRUCTIVE SLEEP APNEA SYNDROME COMPLICATING TO RIGHT SIDED HEART FAILURE WITH CORPULMONALE WITH PULMONARY ARTERY HYPERTENSION, WITH TRICUSPID REGURGITATION, WITH COMPONENT OF LEFT VENTRICULAR FAILURE.
PICK WICKIAN SYNDROME....



“NEVER TAKE SNOARING AS A FUNNY PART PF LIFE,IT MAY TAKE OF THE LIFE IF IS NOT CONTROLLED …….SNOARING AND HEART THUS ARE RELATED TO EACH OTHER BUT ONLY IN ASPECTS OF DELETERIOUS EFFECTS.”

PICTURES OF THE 2DECHO AND COLOR DOPPLER OF THE SAME PATIENT SHOWING PULMONARY HYPERTENSION WITH RVH AND RA DILATATION WITH VERY MILD TR CAN BE SEEN IN MY PHOTO ALBUM AS I COULD NOT PUT THEM HERE.