Heart failure

Case of Heart Failure

 70 yrs old male patient came to the opd with the

 chief complaints of

 Sob since 6 days which was severe

pedal edema since 5 days 

generalized weakness since 5 days

 

History Of Present Illness

Patient was apparently asymptomatic 7 months back then developed generalized weakness  following which he developed sob which was mild 2 days following sob he developed pedal edema pitting type then  contipation for which he went to local doctor and was treated

6 days back he developed sob which was insidious in onset abd progressed to interfere his daily activities  and sleep  

Patient has history of PND 

7 months back Reports 

2 D echo


Ecg
 
Treatment given during last episode




Past History

Nog history of DM HTN CAD ASTHMA  TB

Personal History

married

normal appetite

mixed diet

bowels regular

micturation normal

no allergies 

habits

 alcohol from past 50 years occasional consumer 

Stopped 4 years back

Smoking BD from past 50 years 1 or 2 per day 



On Examination





Pallor No

 Ictrus No

 Cyanisis No

Kolionychia No

Lymphedenopathy  No

Edema Present


Pitting type


SYSTEMIC EXAMINATION 

Cvs

S1 s2 heard no murmurs

Respiratory system

Normal vesicular breath sounds,  no wheeze , no dyspnea , trachea is central

Abdomen

Shape of abd - obese

No tenderness 

No palpable mass, fluid , bruit

No palpable liver  , spleen

P/V , P/R  

CNS 

conscious

response to speech 

no focal deficits

no meningeal signs

no cerebral signs 

Investigation


RBS 188


Blood Urea 24

CUE

Hemogram
Hemoglobin 11.5 gm/dl
Total count 10,500 cells/gm
Lymphocytes 10 % 
PCV 34 vol%
RBC count 3.99


Serum creatinine

 
Electrolytes
Sodium 120 ml/gl
Chloride 82 ml/gl

Ecg


2D Echo



 Treatment

day 1

1 Injection lasix 40 mg  IV/BD

Tab pan 40 mg PO/OD 

Tab aldactone  25 mg PO/OD 

Inj Thiamine 1 amp in 100ml IV /BD 

Tab Ramipril 2.5 mg PO/OD 

Tab Met  xl 12.5 mg PO/OD


Day 2 

1 Injection lasix 40 mg  IV/BD

Tab pan 40 mg PO/OD 

Tab aldactone  25 mg PO/OD 

Inj Thiamine 1 amp in 100ml IV /BD 

Tab Ramipril 2.5 mg PO/OD 

Tab Met  xl 12.5 mg PO/OD


Discharge summary:

Expected date of discharge:


Diagnosis:


Chief complaints:

 70 yrs old male patient came to the opd with the chief complaints of

Sob since 6 days which was severe

pedal edema since 5 days

generalized weakness since 5 days


History of present illness:

Patient was apparently asymptomatic 7 months back then developed generalized weakness  following which he developed sob which was mild 2 days following sob he developed pedal edema pitting type then  contipation for which he went to local doctor and was treated

6 days back he developed sob which was insidious in onset abd progressed to interfere his daily activities  and sleep  

Patient has history of PND 


Past History:

Nog history of DM HTN CAD ASTHMA  TB


Personal history:

married

normal appetite

mixed diet

bowels regular

micturation normal

no allergies 

habits

- alcohol from past 50 years occasional consumer 

 Stopped 4 years back

- Smoking BD from past 50 years 1 or 2 per day 


General examination:

Patient is conscious, coherent, co-operative, oriented to time, place and person.

No pallor, icterus, cyanosis, clubbing, Kolionychia, lymphadenopathy, edema


Vitals:

Afebrile

PR - 84 bpm

BP - 110/70 mm Hg 

RR - 16 cpm

SpO2 - 96% at room air


Systemic examination:

Cvs

S1 s2 heard no murmurs


Respiratory system

Normal vesicular breath sounds, no wheeze , no dyspnea , trachea is central


Abdomen

Shape of abd - obese

No tenderness 

No palpable mass, fluid , bruit

No palpable liver , spleen


P/V , P/R  


CNS 

conscious

response to speech 

no focal deficits

no meningeal signs

no cerebral signs


Treatment

Day 1

1.Injection lasix 40 mg IV/BD

2.Tab pan 40 mg PO/OD 

3.Tab aldactone 25 mg PO/OD 

4.Inj Thiamine 1 amp in 100ml IV /BD 

5.Tab Ramipril 2.5 mg PO/OD 

6.Tab Met xl 12.5 mg PO/OD




Day 2 

1.1 Injection lasix 40 mg IV/BD

2.Tab pan 40 mg PO/OD 

3.Tab aldactone 25 mg PO/OD 

4.Inj Thiamine 1 amp in 100ml IV /BD 

5.Tab Ramipril 2.5 mg PO/OD 

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