A CASE OF HEART FAILURE


A CASE OF HEART FAILURE

UNDER THE GUIDANCE OF Dr KUSUMA

BY Sai Mythili of 2019 batch

A 70 year old male patient came to the OPD with 

CHIEF COMPLAINTS

Severe shortness of breath [dyspnea] since 6 days
Pedal edema since 5 days
Generalized weakness since 5 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 7 months back and then developed generalized weakness following which he developed shortness of breath which was mild
2 days following the sob he developed pedal edema pitting type and then constipation for which he got treated at a local doctor
6 days back he developed sob which was insidious in onset and progressed to interfere in his daily activities and sleep
* Patient has a history of PND[ Paroxysmal nocturnal dyspnea ]

PAST HISTORY
Nog history of Diabetes mellitus
                        Hypertension
                        Coronary artery disease
                        Asthma
                        Tuberculosis

PERSONAL HISTORY

Married
Normal appetite
Mixed diet
Bowels regular
Micturation normal
There are 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 






General examination

NO Pallor 

NO Ictrus

NO Cyanosis

NO Koilonychia

NO Lymphadenopathy

Edema Present :Pitting type









SYSTEMIC EXAMINATION 

CVS

S1 and S2 heard there are no murmurs

RESPIRATORY SYSTEM

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

ABDOMEN

Shape of abdomen - obese

No tenderness 

No palpable mass, fluid , bruit

No palpable liver  , spleen

P/V , P/R  

CNS 

Is conscious

response to speech 

no focal deficits

no meningeal signs

no cerebral signs 

INVESTIGATIONS

Random Blood Sugar:188 mg/dl


Blood Urea: 24 mg/dl

Complete urine examination

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

Electrocardiogram


2D Echo


X-RAY







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








 














Comments

Post a Comment

Popular posts from this blog

A CASE OF MULTIPLE JOINT PAINS UNDER EVALUATION ASSOCIATED WITH POTASSIUM IMBALANCE

Image
A 31 years old female,who is a house wife ,came from janagon district with complaints of  Cheif complaints : Deformity of bilateral knuckles  Loss of sensation in upper limb and lower limb with neck five days back Came for management  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 1 year ago,and then she developed pain in right hand follow by ulnar deviation of fingers at second metacarpalophalengeal joint and progressed to 3rd,4th and 5th metacarpalophalengeal joint in a period of 1 month. She developed pain in the joints :  bilateral wrists  bilateral elbow  Bilateral shoulder joints Bilateral ankles  Bilateral knees No pain in toes She also developed swelling of her bilateral soles because of which she was unable to walks She went to a rmp for which she was given some medicine and used during which pain decreased later on when she stopped those medication she again developed pains all over the joint She used on and off when ever she...
Read more

A CASE OF DENGUE

Image
“This is an online e log book to discuss our patient’s de- identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.” A 68 year old Female patient who is a resident of choutuppal came to the OPD with CHIEF COMPLAINTS Giddiness Generalised weakness since 5 days Fever since 1day Nausea and vomiting Diarrhea NS1 positive HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 1 week back when she developed high grade fever associated with chills and rigor along with nausea , vomiting with diarrhea The vomiting was since 4 days non projectile and contains food particles about 4 times a day The diarrhea also sin...
Read more

LEARNING THROUGH CLINICAL PROBLEM SOLVING (A CASE OF CHOREA)

Image
Hello Everyone! I am Mythili, a 2 nd year MBBS student and I have chosen to explore a case of CHOREA through this year's clinical problem solving conference The following is the link for this semi structured case: (http://snehakalyankar.blogspot.com/2021/12/chorea.html)  My objective for today would be to  *Prepare a problem list  and Identify the patient problem solution requirements in terms of priority   *Suggest current standard evidence based solutions (mentioning the RCT evidence available in a PICO format)     *Suggest innovative solutions (mentioning how they may design an ethical trial to scale their proposed innovative solution MAKING A PROBLEM LIST Let us  understand the entire problem  by using a time line The problems can be classified as The problems patient came to us with( abnormal movements, behavioral problems, ulcers, fever)  The problems we found through investigations (Increased copper Secretary leve...
Read more