202102608

 

A 60 year old male patient was apparently asymptomatic 2 months back then he developed shortness of breath . On exertion , which progressed to grade 4 associated with orthopnea and paroxysmal nocturnal dyspnea
Pedal edema since 2 months , bilateral from ankle to knee associated with abdominal discomfort and tightness
Decreased urine output since 2months associated with burning micturition
Generalized weakness since 2 months associated with pain in bilateral lower limb
History of past illness:
Patient was apparently asymptomatic 2 years back then he developed weakness in the right upper and lower limb, loss of speech. He used medication for 6 months and his weakness improved on which he stopped medication and loss of speech persisted.

Past history-

N/K/C/O- Diabetes, asthma, tuberculosis.

No H/o blood transfusions.

H/o Tubectomy  done 23 years ago.

Personal history-

Normal appetite.

Diet- vegeterian

Bowel and bladder movements - constipated

Addicted to alcohol.

No known allergies.

Family history- insignificant.

O/E :

 Patient is conscious,well orientated to time,place and person.

Pallor - present. Bilateral paedal edema present 

No icterus, clubbing, cyanosis, lymphadenopathy.

Height:168 cm   weight:50kg

BMI: 17.71 Kg/m2

Vitals:

Temperature- 98.4 F

Pulse rate- 78Bpm regular.

Blood pressure- 140/100 mm of Hg in rt.arm 

RR- 17cpm

CVS:

INSPECTION:

 No visible apical impulse.no pricardial bulge, visible pulsations,dilated veins

PALPATION:

Apex beat felt at 5 th ICS.

Thrills- present at apex.

PURCUSSION-

AUSCULTATION- 

Loud S1 present;loud P2 present;S3 Accentuating on inspiration- RVS3; Expiration - LVS3

Cervical veinous hum - present.

RESPIRATORY SYSTEM:

Dyspnea present.

Trachea appears to be central.

Shoulders are at same level.

No pectus excavatum or pectus carinatum.

No visible pulsations,dilated veins and scars.

Normal vesicular Breath sounds heard.

Bilateral  fine Crepitations  present in axillary,infra axillary and infrascapular areas.

P/A:

Distended abdomen

No palpable mass

Bowel sounds heard

CNS-

Higher Mental functions :Intact
No signs of meningeal irritation
(Kernigs sign_negative,Brudzinski Sign_negative)
Cranial nerves: intact
Motor system: intact
Sensory system:intact

REFLEXES            RIGHT.          LEFT

Biceps                  2+.                  2+

Triceps.                 2+.                  2+

Knee jerk.              2+.                  2+

Ankle jerk.             2+.                 2+

Plantar reflex.        Flexor.          Flexor


Provisional diagnosis- 
HRrEF secondary to CAD

Investigations:

Hemogram:

LFT:

ECG:

2D ECHO:

Ultrasound:

Serum creatinine:

Blood urea:


Treatment:

Tab. Lasix 40 mg bd

Tab. Benfomet plus od

Tab. Telma 40 mg od

Tab. Met xl 50mg od

Tab. Aldactone 25mg od

Tab.Ecosprin-AV 75/10 mg od

Salt restriction <2gm/day

Fluid restriction<1.5lit/day

BP, pulse, spO2, temperature 4th hourly monitoring.


On 2/2/2021

S- No fresh complaints

O- 

     Temperature: 98f

     Bp: 140/90 mm Hg

     Pr: 76 bpm

     Rr: 17 com

A-

     HRrEF secondary to CAD

P-

    Tab. Lasix 40 mg bd

Tab. Benfomet plus od

Tab. Telma 40 mg od

Tab. Met xl 50mg od

Tab. Aldactone 25mg od

Tab.Ecosprin-AV 75/10 mg od

Salt restriction <2gm/day

Fluid restriction<1.5lit/day

BP, pulse, spO2, temperature 4th hourly monitoring .

On 3/2/2021:

S- No fresh complaints

O- 

     Temperature: 98f

     Bp: 100/60 mm Hg

     Pr: 60 bpm

     Rr: 17 com

A-

     HRrEF secondary to CAD

P-

Tab. Lasix 40 mg bd

Tab. Benfomet plus od

Tab. Telma 40 mg od

Tab. Met xl 50mg od

Tab. Aldactone 25mg od

Tab.Ecosprin-AV 75/10 mg od

Salt restriction <2gm/day

Fluid restriction<1.5lit/day

BP, pulse, spO2, temperature 4th hourly monitoring .




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