E LOG

CASE OF HEART FAILURE..

(Under the guidance of  Dr. G. Kusuma ma'am  intern)  

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".

Case as follows:

70 yrs old male patient came to the OPD  with the chief complaints of shortness of breath 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 shortness of breath which was mild 2 days following shortness of breath he developed pedal edema pitting type then constipation for which he went to local doctor and was treated
• 6 days back he developed shortness of breath which was insidious in onset and progressed to interfere his daily activities  and sleep  
• Patient has history of Paroxysmal nocturnal dyspnea (PND)
• 7 months back Reports 

2 D echo

ECG

 
Treatment given during last episode

Past History:

No history of DM HTN CAD ASTHMA  TB

Personal History:

• Married
• Appetite: normal appetite
• Diet: mixed diet
• Bowels regular
• Micturition 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:

General examination:

• Patient is conscious, coherent, co-operative, oriented to time, place and person.
• No pallor
• No icterus
• No cyanosis
• No clubbing
• No Koilonychia
• No lymphadenopathy
• Edema Present

Pitting type

• 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 abdomen - 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 

Investigations:

RBS 188

Blood Urea 24

CUE

Hemogram

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

Serum creatinine

 

Electrolytes

• Sodium 120 mEq/L  
• Chloride 82 mEq/L

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

Day 3 

Same medication and symptoms relieved.

Day 4 

Same medication followed patient stabled and relieved.

Day 5 

Discharged