68/F with SOB since 3 days


December 27, 2021
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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


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