68/F with SOB since 3 days

December 27, 2021

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.  

 

68 year old female patient came with complaints of SOB since 3 days 

HOPI 

Patient was apparently asymptotic 3 years ago then she had shortness of breath and diagnosed with CAD and PTCA was done to LAD 

1year ago she had SOB , angiogram was repeated :triple vessel disease + , but creatinine started to raise and stunting not done 

Patient was admitted and discharged 1week ago for SOB , Acute on Chronic Heart Failure , for which she was prescribed 

Tab.ecosprin gold,

Tab. cardivas 3.125mg,

Tab. Hydralazine 12.5mg,

Tab. Pregabalin 75mg,

Tab. Dytor 10mg ,

Syp. Potchlor 

patient was fine after discharge for 2 days 

Now since 3 days patient had complaints of SOB Grade 4 and pedal edema 

No complaints of decreased urine output, Fever , cough , Facial puffiness .

Past history: 

 K/c/o CAD since 3yrs 

N/k/C/O HTN/ DM / BA 

Personal history: 

Diet - mixed 

Appetite- normal 

Sleep - adequate 

Bowel and bladder movements- regular 

Addictions - no 

GENERAL PHYSICAL EXAMINATION:

Pt is conscious,coherent,cooperative 

Moderately built and nourished

No pallor, icterus, clubbing,cyanosis,lymphadenopathy,edema of feet

Vitals:

Temp-98 F

PR-58 bpm

BP-130/90 mm hg 

Spo2- 64% @ room air

GRBS -98mg/dl 

SYSTEMIC EXAMINATION:

CVS- S1S2 +

RS - BAE+, NVBS+

P/A - soft, non tender , bowel sounds +

Provisional diagnosis:

•Cardiogenic pulmonary edema,

•HFrEF (Ef=36%) secondary to CAD 

Moderate to severe LV dysfunction with severe MR 

? Cardio- Renal syndrome Type 2 

Investigations:

Hemogram  

Hb - 7.8gm/dl 

TLC - 11,600

PlC - 2.86 lakhs /cumm 

CUE : 

Albumin - Nill

Sugars - Nill 

Pc - 2-3 

Ec - 2-4 

LFT: 

TB - 0.69 

DB- 0.26 

SGOT -44 

SGPT - 25 

TP- 6 

ALB- 3.6 

RFT: 

CREAT - 2.5 

UREA - 100 

Na- 146 

K - 5.6 

Cl- 102

Treatment:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

3.nebulisation with duolin,budecort / stat

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

8.Tab B- complex /PO/OD

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

                   28/12/21 (Day 1)

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 82 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HFrEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

3.nebulisation with duolin,budecort / stat

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

8.Tab B- complex /PO/OD

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

                           29/12/21

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 80 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HErEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

7. T. Ultracet po/sos

8.Tab B- complex /PO/OD

8. Syp. Lactulose 5ml po/hs

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

30/12/21

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 78 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HErEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

7. T. Ultracet po/sos

8.Tab B- complex /PO/OD

8. Syp. Lactulose 5ml po/hs

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

1.Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. T. Lasix 40mg po/BD

3. T. ultracet po/sos

4. T. Dytor 10mg po/od

5. T cardivas 3.125 mg po/od (2pm)

6. T. Ecospirin gold (75/75/20) po/od (8pm)

7. T. hydralazine 12.5mg/PO/TID (8am--2pm--8pm)

8. T. Orofer-XT po/od

9. T. Nodosis 550mg po/bd

10. T. PANTOP 40mg po/od

11. Syp. Lactulose 5ml po/sos