A 70 year old male patient elog

 70 Year old male patient elog


June 23, 2021


A 70 year old male patient who is a farmer and a resident of choutuppal presented to the op with chief complaints of shortness of breath and swelling in legs since 6 days


History of present illness:

•8 months ago,

the patient experienced shortness of breath after being exposed to heavy rain and later had swollen legs and could not pass stools for 2days after which he had consulted the doctor.

•He was admitted in the hospital for 4 days and was referred to another doctor who had prescribed him the medications which he used for the past 7 months but the regularity in taking the medicine was not monitored

Previous medication


•2 days back, the patient came with similar complaints of swollen legs(was always present but aggravated since a week) and

•shortness of breath (since1 day) and weakness. Also complaints that the shortness of breath aggravated when he ate or performed any heavy work.


Past history:

1.patient had swelling in the scrotum since 5 years but had been ignoring it and has not taken any medications since onset

2. Surgery for the swollen scrotum has been denied by the doctors 1 month ago due to the condition of his heart

3. No H/O HTN,DM and epilepsy


Personal history:


Married

Diet: mixed

Appetite: lost

Sleep: adequate

Regular bowels

Normal micturition

No allergies

*H/O tobacco smoking till 6 years back i.e 2015

*Alcohol consumption is occasional and moderate


Family history:

No history of DM, HTN

Attender mentions that shortness of breath runs in the family [in patients mother and uncle(mothers brother)]


General examination 





Patient is conscious, coherent, cooperative, oriented to time, place and person.

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy


Edema present (pitting type)


 


Vitals


Afebrile

PR -  84bpm

BP - 100/60mm hg

RR - 60 com

SpO2 - 96% at room air


Systemic examination 


CVS

No thrills

No murmur

Heart sounds S1 S2 heard


Respiratory

No dyspnea

No wheeze

Position of trachea - Central

Breath sounds - Vesicular


Abdomen

Shape - scaphoid

No tenderness

No palpable mass

Hernial orifices - Normal

No free fluid

No bruits

Liver - not palpable

Spleen - not palpable

Bowel sounds - Present


CNS

Patient is conscious, coherent

Response to speech


Provisional diagnosis 

   Heart failure 

(Edema might suggest pooling of blood at lower extremities, 

low contractility and less cardiac output of heart due to which there is less oxygen availability to tissues and hence shortness of breath is seen)


Plan of treatment 

    Conservative

Prognosis

    Inadequate so far

Investigations:

          

                        Ultrasound report:





2D echo:





Hemogram:

                                  
                                  ECG:

 Clinical diagnosis 


   HFrEF   ē  Dcmp (heart failure with reduced                                            ejection fraction )

                (EF - 25%)


TREATMENT
Injection lasix 40mg IV/TID
Injection thiamine 1 amp in 50ml/ns/hr
Tab Metalazone 5mg PO/OD
Tab Ramepril 2.5mg PO/OD
Tab Aldactone 25mg PO/OD
Tab MET-XL 25mg PO/OD
Tab pan 40 mg PO/OD
BP/PR jump monitoring 9th hour
GRBS charting 12th hourly 
Strict I/O charting

PROGRESS:

HFrEF (EF - 38%)  ē DCMP
   ē moderate to severe PAH
C/O  SOB Gr III (resolving)
pedal edema present

BP - 120/70
PR - 76bpm
CVS S1 S2 heard
RS BAE present
weight - 45kg

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