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05/08/2026

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When Mrs G, a 30-year-old woman, came to my clinic, her main complaints were that her legs had become swollen, she was ...
30/07/2026

When Mrs G, a 30-year-old woman, came to my clinic, her main complaints were that her legs had become swollen, she was getting tired easily, and she felt uncomfortable because of swelling around her abdomen.

She explained that the swelling had gradually increased over several weeks. She also noticed that she was gaining weight despite not eating more than usual. Walking short distances had become more tiring, and she sometimes felt a heavy sensation around her chest and upper abdomen.

I reassured Mrs G that we would carefully assess her condition and develop a treatment plan to help her heart work better and reduce the symptoms.

Mrs G’s Condition When She Arrived

Her vital signs were:

- Blood pressure: 110/70 mmHg
- Pulse rate: 96 beats per minute
- Respiratory rate: 20 breaths per minute
- Temperature: 36.7°C
- Oxygen saturation: 96% on room air
- Weight: 78 kg

She was alert and able to communicate well but appeared uncomfortable because of the swelling in her legs and abdomen.

The symptoms she reported included:

- Swelling of both legs, especially around the ankles
- Right sided Abdominal swelling and a feeling of fullness
- Easy tiredness and reduced ability to exercise
- Weight gain due to fluid retention
- Reduced appetite because of abdominal discomfort
- Occasional shortness of breath, especially when lying down
- Feeling generally weak

From the history we ruled out left heart failure as there was no fast or difficult breathing

During my examination, I noticed:

General Examination

- She had swelling around both ankles and lower legs (bilateral pitting oedema).
- There was mild left abdominal distension
- No signs of severe breathing difficulty.
- She was not pale or jaundiced.

Cardiovascular Examination

- Her pulse was slightly fast but regular.
- The veins in her neck were visibly raised (raised jugular venous pressure/JVP), suggesting increased pressure in the veins.
- Heart sounds were present, and there was a extra heart sound(A pansystolic murmur) heard over the 4th left sternal border ( A possible Tricuspid regurgitation)

When a doctor listens with a stethoscope, the main normal heart sounds are:
S1 ("lub") → caused by closure of the mitral and tricuspid valves when the ventricles start contracting.
S2 ("dub") → caused by closure of the aortic and pulmonary valves when the ventricles finish contracting.
These are the normal sounds of the heartbeat.

What Is a Murmur?
A murmur is a extra whooshing, blowing, or vibrating sound heard between or around the normal heart sounds.
It happens when blood flows in a turbulent way instead of smoothly.

Think of it like water flowing smoothly through a pipe versus water rushing through a narrowed or leaking pipe — the disturbed flow creates noise.

Respiratory Examination

- Her lungs were mostly clear.
- There were no major signs of fluid collection in the lungs, which is more typical of left-sided heart failure.No bilateral basal crepitations

Abdominal Examination

- Her liver was mildly enlarged and tender due to congestion from backed-up blood flow.
- There was evidence of fluid accumulation in the abdomen.

These findings were consistent with right-sided heart failure.

Investigations We Performed

To understand the cause and severity of Mrs G’s condition, we carried out several tests.

Echocardiogram (Heart Ultrasound)

This showed:

- Enlargement and reduced pumping ability of the right side of the heart.
- Assessment of heart valves revealed a downward displaced tricuspid valve which led to backflow of blood from right ventricle back to right atrium and heart pressures

Clinically we suspected it was a Right Heart failure following a tricuspid regurgitation as the murmur gave it away but Echò revealed Atrial Septal defect with an Ebstein anomaly

What is Atrial septal defect with Ebstein anomaly?

Ebstein anomaly is a rare congenital heart defect in which the tricuspid valve (the valve between the right atrium and right ventricle) develops abnormally and is displaced downward into the right ventricle.

Because the valve is positioned too low:
Part of the right ventricle becomes functionally part of the right atrium ("atrialisation" of the right ventricle).

The tricuspid valve often becomes leaky (tricuspid regurgitation).
Blood flows backward from the right ventricle into the right atrium.

The right atrium becomes enlarged, and the right side of the heart becomes overloaded.
Over time, this can lead to:
Right-sided heart failure
Abnormal heart rhythms (arrhythmias)
Reduced exercise tolerance
Fluid retention (leg swelling, enlarged liver, abdominal swelling)

Ebstein anomaly commonly occurs with an atrial septal defect (ASD) or a patent foramen ovale (PFO).

An ASD is a hole between the two upper chambers of the heart.
Normally: Right atrium → Right ventricle → Lungs

With an ASD:
Blood can pass between the atria.
Usually, oxygen-rich blood from the left atrium moves into the right atrium.
This increases blood flow through the right side of the heart.
The already abnormal right heart in Ebstein anomaly becomes even more overloaded.

Other tests we did included Electrocardiogram (ECG)

This checked the electrical activity of her heart and looked for:

- Abnormal heart rhythms
- Signs of heart strain

Chest X-ray

This helped assess:

- Heart size
- Lung condition
- Signs of fluid overload

Blood Tests

We checked:

- Full Blood Count: To look for anaemia or infection.
- Kidney function tests: Important before using diuretics.
- Electrolytes (sodium and potassium): To monitor fluid treatment.
- Liver function tests: Because right heart failure can affect the liver.
- BNP/NT-proBNP: A marker that can support the diagnosis of heart failure.

Additional Tests Depending on Cause

Because right-sided heart failure in a younger person can have several causes, we considered tests for:

- Lung disease
- Blood clots in the lungs
- Heart valve problems
- Congenital heart disease

These could be the possible causes of RHF in a 30 year old

Pulmonary hypertension
Congenital heart disease (especially ASD)
Pulmonary embolism
Heart valve disease( Tricuspid heart disease, Ebstein abnormality)
Cardiomyopathy
Connective tissue diseases (e.g., lupus)
Long-standing lung disease
Pregnancy-related heart problems (if relevant)

How we Treated Mrs G

The main goals of treatment were to control symptoms

1. Reduce excess fluid in her body.
2. Help the heart pump more efficiently.
3. Treat the underlying cause.
4. Prevent further damage.

Mrs G was started on loop diuretic

How it works:

Loop diuretics helps the kidneys remove extra salt and water from the body through urine.

This reduces:

- Leg swelling
- Abdominal fluid
- Pressure on the heart

I explained that she may pass urine more frequently after taking it, especially in the first few hours.

She was also started on a potassium sparing diuretic or ( Aldosterone receptor blocker)

How it works:

Spironolactone blocks the hormone aldosterone, which causes the body to retain salt and water.

It helps:

- Reduce fluid buildup
- Protect the heart from further damage

Her potassium levels would need monitoring while taking this medicine because too much potassium in the body(as well as too little) could lead to problems like abnormal heart rhythms and beats( palpitations

Other Heart Failure Medications depend on heart functions

If appropriate after assessment, medicines such as:

ACE inhibitors or blockers
relax blood vessels, reduce the workload on the heart, and help protect the heart muscle.

They do this by blocking production of Anngiotensin II (which construicts or presses the blood vessels/arterioles.

Blocking it relaxes the arterioles thereby reducing afterload( resistance in vessels to heart pumping) and some preload ( reduction in blood returning to heart leading to a subsequent reduction in blood pumped out which reduces blood pressure )

Oxygen is given when necessary but there was no need in our patient

Others used when necessary are Beta blockers and antiarrhythmics especially for patients with tachycardia or heart beating too fast

How they work:
They slow the heart rate slightly and allow the heart more time to fill and pump efficie

These medicines are introduced carefully depending on blood pressure and the exact type of heart failure.

After treatment and lifestyle changes, Mrs G noticed:

- Reduced leg swelling
- Less abdominal discomfort
- Improved energy levels
- Better ability to walk and perform daily activities

Her weight reduced as excess fluid was removed.

I explained that medication alone is not enough. Daily habits play an important role.

1. Reduce Salt Intake

Too much salt causes the body to hold water.

She was advised to:

- Reduce salty foods
- Avoid adding extra salt to meals
- Be careful with processed foods

2. Monitor Weight Daily

I advised her to weigh herself regularly.

A sudden increase in weight may mean fluid is building up again.

3. Take Medicines Regularly

Heart failure medicines work best when taken consistently.

She should not stop medications suddenly without medical advice.

4. Keep Active

Gentle exercise, as tolerated, helps improve strength and quality of life.

5. Recognise Warning Signs

She was advised to seek medical help if she develops:

- Increasing leg swelling
- Rapid weight gain
- Worsening breathlessness
- Chest pain
- Fainting
- Severe tiredness

6. Keep Follow-Up Appointments

Regular reviews allow us to:

- Check kidney function
- Adjust medicines
- Monitor heart function

She was referred to a Heart Surgeon for possible

Repair of the Tricuspid Valve (Preferred When Possible)

The surgeon may:
Reconstruct the abnormal tricuspid valve.
Improve valve function.
Reduce backward leakage of blood.
A common modern repair technique is the cone repair, which reshapes the valve leaflets to create a more functional valve.

B. Closure of the ASD
The ASD may be closed:
Surgically, during heart surgery
or
Sometimes through a catheter device (in selected cases)

Important: In some patients with severe Ebstein anomaly, the ASD is not closed immediately because it may act as a "pressure release pathway" for the right heart. The decision depends on heart pressures and specialist assessment.

C. Valve Replacement
If the tricuspid valve cannot be repaired, replacement may be considered.
Options:
Biological valve
Mechanical valve (less commonly preferred in some situations)

Final Message to Mrs G

I explained to Mrs G that having heart failure does not mean life has to stop. With the right medicines, lifestyle changes, and regular medical care, many people with heart failure are able to live active and fulfilling lives.

The aim of treatment is not only to reduce symptoms but also to help her heart work better and prevent future complications.

16/07/2026

Urinary schistosomiasis (S. haematobium)
Blood in urine (haematuria) — classic symptom
Painful urination
Increased frequency of urination
Lower abdominal pain
Bladder scarring
Kidney damage in severe cases

16/07/2026

Schistosomiasis
Itchy rash ("swimmer's itch")
Redness/ small bumps at the entry site
Fever, Muscle aches,fatigue

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