68 YEAR OLD FEMALE WITH SHORTNESS OF BREATH

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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 

65 year old female who used to work as a tailor came to casualty with complaints of shortness of breath since 6 days ,even in sitting position.She also complaints of swelling of limbs since 6 days ,pitting type of edema upto knee since 2 weeks .decreased appetite and increased thirst since 2 days 


HOPI:
patient was apparently asymptomatic 10 years back later she developed SOB ,swelling of whole body for which she was admitted in hospital on 1/7/2012 for which she was diagnosed having dilated cardiomyopathy and severe LV dysfunction and she was in lasix and later got checked  every yearly on 2D echo which showed following findings 

2014: LV dysfunction, moderate MR/TR,moderate  PAH ,mild AR

2015: decomponsated heart failure / NYHA CLASS III

2016 : admitted with dyspepsia ,vomiting ,cough,SO ,sleepiness and used DYTOR for that and on 2016 June diagnosed to have left sciatica 
2017 : went to hospital with dry cough ,sob ,chest pain and EF=20%

2018: having SOB II ,cough and syncope 

2022: on 25th april went to hospital with loss of appetite ,abdominal discomfort and dysphoria and for which ecg was done and p waves were absent and urea of 52.81 value is observed ,s.creatinine - 3.06 on 25/04/22,rbs: 143 
And patient is on medication for that 
SPRINOLACTONE, AMIADARONE,TORSEMIDE,DIGOXINE, DABIGATRIN 

Past history:
Not a k/c/o DM 
k/c/o HTN since 3 years on medication (not known)
Now on spirnolactone ,amiodarone,torsemide ,HCT ,digoxin ,dabigatran

Family history:
Not significant 

Personal history:
Bowel and bladder regular 
No habits / addictions
Menopause obtained


General examination:
Pallor + 
No icterus/cyanosis/clubbing 
Oedema of feet present 



Vitals :
Temp- afebrile
Pr- 86bpm
Rr- 16cpm
BP-110/70 mmhg
Spo2-96% on RA
GRBS- 115mg/dl

Systemic examination:
CVS -s1s2 heard 
CNS - NAD
Respiratory system - dyspnoea present 
BAE+,NVBS HEARD
P/A - soft non tender 


Investigations:


Blood urea- 30 

S.creatinine -1.1

Serum electrolytes:
Na+   140
K+       4.1
Cl-       99

Hemogram :
HB- 12.3
TLC-8500
Plt- 1 78 lkhs
RBC-3.88 million

LFT:
Total bilirubin-2.07
Direct bilirubin-0.58
SGOT               - 41 
SGPT             -   119
ALP               -   183
Total proteins -5.5
Albumin -      3.59

Ecg on 29/4/22:

Ecg 30/4/22

2d echo 

30/4/22
2/5/22
Provisional diagnosis:
DILATED CARDIOMYOPATHY WITH HYPERTENSIVE HEART DISEASE 


Treatment :
1.TAB DYTOR 10MG PO BD
2  TAB ALDACTONE  50NNG PO OD
3.TAB HYDRALAZINE 12.5MG OD 
4.TAB AMIODARONE 200MG OD
5.TAB DABIGATRAN 110 MG PO OD 
6.TAB PAN 40 MG PO OD
7.SALT AND FLUID RESTRICTED DIET
8.INJ UNFRACTIONATED HEPARIN BD 
5000 IU S/C OR IV 


1/5/22
S:
Complanits of Shortness of breath  Decreased 


O:
Pallor + 
No icterus/cyanosis/clubbing 
Oedema of feet present 

Vitals :
Temp- afebrile
Pr- 86bpm
Rr- 16cpm
BP-100/60 mmhg
Spo2-96% on RA
GRBS-118 mg/dl

Systemic examination:
CVS -s1s2 heard 
CNS - NAD
Respiratory system - dyspnoea present 
BAE+,NVBS HEARD
P/A - soft non tender 


A:
DILATED CARDIOMYOPATHY WITH HYPERTENSIVE HEART DISEASE 

P:
1.TAB DYTOR 10MG PO BD
2  TAB ALDACTONE  50MG PO OD
3.TAB HYDRALAZINE 12.5MG OD 
4.TAB CARDRONE  200MG PO /OD
5.TAB DABIGATRAN 110 MG PO OD 
6.TAB PAN 40 MG PO OD
7.SALT AND FLUID RESTRICTED DIET
8.INJ .CLEXANE 60MG SC /OD


2/5/22
S:
Complanits of Shortness of breath  Decreased 


O:
Pallor + 
No icterus/cyanosis/clubbing 
Oedema of feet present 

Vitals :
Temp- afebrile
Pr- 86bpm
Rr- 16cpm
BP-110/70 mmhg
Spo2-96% on RA
GRBS- 140mg/dl

Systemic examination:
CVS -s1s2 heard 
CNS - NAD
Respiratory system - dyspnoea present 
BAE+,NVBS HEARD
P/A - soft non tender 


A:
DILATED CARDIOMYOPATHY WITH HYPERTENSIVE HEART DISEASE 

P:
1.TAB DYTOR 10MG PO BD
2  TAB ALDACTONE  50MG PO OD
3.TAB HYDRALAZINE 12.5MG OD 
4.TAB CARDRONE  200MG PO /OD
5.TAB DABIGATRAN 110 MG PO OD 
6.TAB PAN 40 MG PO OD
7.SALT AND FLUID RESTRICTED DIET
8.INJ .CLEXANE 60MG SC /OD

Popular posts from this blog

A 42 Year old woman with multiple health events since birth

Image
Hi everyone, this is chandan  4th year mbbs student and i was given a case to learn better in approaching a case. Case given to me is in the link given below:👇 https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Case: It was a 42yr old female with Chief complaints::: 1.Loss of coordination ,numbness on the left side. 2.Breathing problems. 3.Salt cravings. 4.Swelling. 5.Poor stress response Reasons for the problems: 1.Loss of coordination and numbness on the left side indicating like left sided hemiplegia. -causes can be Brain infections,Brain tumors,Genetic abnormalities. -she also suffered with very long duration of migraine and severe headache;hemiplegia associated with migraine can be hemiplegic migraine which is a genetic abnormality due to mutation of genes like ATP1A2,SCN1A. -she has low vitamin B12 levels which causes demyelination of neurons ,may be a cause for loss of coordination and spinnimg movements. 2.Breathing pro...
Read more

A 60 HR OLD FEMALE WITH ANEMIA SECONDARY TO CKD

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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" A 60 yr old female came to opd with the  Chief complaints: -Shortness of breath on exertion grade 2-3 MMRC  since 5 days -B/L Pedal edema worsening   since  5 days  -Decreased urine output worsening since 5 days History of presenting illness: Patient was apparently assymptomatic 20 years back , she developed pedal edema and decreased urine output ,shortness of breath   since 1 year   -  Edema B/l pitting type extending from ankle to below k...
Read more

A 60 YEAR OLD MALE WITH COMPLAINTS OF GIDDINESS

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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" This is case of 60 year old male came to casualty with chief complaints : Patient c/o giddiness since 6days C/o headache since 6days Hopi: Patient was apparently sympatomatic 10 years back then he had stomach ache for which he was referred to our hospital. Then he was diagnosed with intestinal perforation and he was operated and discharged after 6 days.  4yrs back he fell in drainage pit and got ankle fracture. And he got nail plate operated and removed after 1 month 6 days bac...
Read more