35 year old male with SOB and Pedal edema


Case presentation:

35 year old male  labourer  by occupation who is the resident of  nalgonda    presented with pedal edema since 1 month and sob since yesterday

Patient was apparently asymptomatic 1 month back later he developed pedal edema Which was gradual in onset  progressed to knee , associated with facial puffiness then he went to chityala and he has taken the medications which was prescribed by local doctor ,symptoms got relieved.

 Then yesterday night he developed pedal edema associated  sob which was sudden in onset 

No aggrevating and relieving factors 

For which his wife fed 1 bread and milk and later he vomited.

No h/o chestpain 

No h/o palpitations


Past h/o : 

No similar complaints in past

N/k/c/o DM , HTN ,ASTHMA ,CAD, EPILEPSY,TB


Personal h/o :

sleep adequate 

Diet mixed 

Decreased urine output since morning

Addictions : 

Patient started consuming alcohol since 17 yrs ( unadulterated tody and whiskey 180ml once in 15 days gradually increased to 360ml of whiskey in the span of 10 yrs)

From past 5- 6 years he developed binge drinking pattern and would drink on days he had money . He used to drink for 3- 4 days continuously and he don't drink for the  next 15 days and his last drink was on 12th oct ( 750ml whiskey) 

H/o of tobacco chewing ( 1 packet / day ) since 17 yrs 


On examination -

Pt was unresponsive with frothing with spo2 48%

 In view of falling saturation , patient was intubated with ET 7 , Inj Midazolam 2cc/w/stat , Inj glycopycolate 2cc/ stat  with inj NORAD - DS @6ml/hr 

Started on Inj Dobutamine @1ml/hr 


No pallor ,

No icterus ,

No cyanosis ,

No clubbing,

Bilateral pitting type of pedal edema is present upto knee

His vitals :

Afebrile to touch  

Bp - not recordable ( at 3: 30 am)

Bp at 4:00am - 60/40 mmhg

Pulse - feeble 

RR - 30cpm

Spo2 - 48% at room air 

GRBS - 148mg%


Systemic : 

P/A : 

Shape of abdomen : obese 

no scars , sinuses ,no distended veins ,hernial orifices free ,soft 

No tenderness 

RS : BAE + Nvbs heard 

No added sounds 

CNS : NAD

CVS  :

S1 S2 heard 

No murmurs 


Day1-

Investigations ordered  : 

Ecg




2d echo




HRCT



HbsAg




Blood c/s






CHEST X RAY : 




Treatment given : 

HEAD END ELEVATION

OXYGENATION TO MAINTAIN SPO2>90%

Intermittent BIPAP

INJ NORAD - DS ( 2 AMP IN 20 ML NS @0.5 ML/ HR 

INJ DOPAMINE 1 AMP IN 20 ML NS @0.5ML /HR 

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 4.5MG/IV/ STAT

INJ THIAMINE 1 AMP IN 100ML NS/ IV/BD 

I/O CHARTING 

DAILY WEIGHT MONITORING 

BP/ PR HOURLY 


Provisional diagnosis on admission: 

Acute decompensated heart failure with ischemic hepatits with AKI  ( DCMP SECONDARY TO ALCOHOL)


Day 2-


No fresh complaints 

SOB - decreased


O/E : 

Patient is sedated , pupils : sluggish to light 

No signs of icterus ,cyanosis , clubbing


Vitals : afebrile 

BP - 80 /40mmhg 

PR - 117 bpm

GRBS - 123 mg %

OUTPUT - 75ml

CVS -S1 S2 + 

RS - BAE + ,NVBS

P/A - SHAPE OF ABDOMEN - OBESE

CNS - NFND 

Investigations 


RFT


LFT 



Treatment given: 

HEAD END ELEVATION

CHANGE POSITION FREQUENTLY

ORAL SUCTION 2ND HOURLY 

RT FEEDS ( 2ND HOURLY - 30 ML MILK 

HOURLY - 50 ML WATER )

INJ NORAD - DS ( 2 AMP IN 20 ML NS @0.5 ML/ HR 

INJ DOPAMINE 1 AMP IN 20 ML NS @0.5ML /HR 

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 4.5MG/IV/ STAT

INJ THIAMINE 1 AMP IN 100ML NS/ IV/TID

INJ LASIX ( 20 MG/ HR ) 

IVF - 10MLNS + 10 ML LASIX @ 5 ML/ HR IF SBP > 100MMHG

I/O CHARTING , GRBS 8TH HOURLY

BO/ PR HOURLY /SPO2

Diagnosis- Acute decompensated heart failure with ischemic hepatits with AKI  ( DCMP SECONDARY TO ALCOHOL) with ISCHEMIC HEPATITS 

WITH AKI


Day 3 

No fresh complaints 

Pedal edema - decreased

O/E : 

Patient is Conscious, coherent

Pupils - NSRL

I/O - 1610/6000ml


Vitals : afebrile 

BP - 120/80 mmhg 

PR - 92 bpm, normal volume , regular

GRBS - 112mg %


CVS - S1 ,S2 + ,JVP - NORMAL 

RS - BAE + ,NVBS

P/A - Obese, soft , non tender.

CNS - NFND 

Investigations: 

Hemogram 



RFT 



LFT



CUE 



PT 



APTT



Treatment given: 

HEAD END ELEVATION

RT FEEDS ( 2ND HOURLY - 30 ML MILK , HOURLY - 50 ML WATER )

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 2.25MG/IV/QID

INJ THIAMINE 1 AMP IN 100MG / IV/TID

INJ LASIX ( 40 MG/ IV / TID HR ) IF SBP > 100MMHG

TAB AZITHROMYCIN 500MG / OD

NEB WITH MUCOMIST - 6TH HOURLY 

BUDECORT - 12TH HOURLY 

CHEST PHYSIOTHERAPY FOR 4TH HOURLY 

ORAL FLUIDS UPTO 1.5 LIT/DAY 

ALLOW SOFT  DIET 

SYP MUCAINE  GEL 15 ML - 15 MIN BEFORE EACH MEAL 

INJ HYDROCORTISONE 100MG/ IV / STAT 

I/O CHARTING 

BO/ PR HOURLY /SPO2


Diagnosis : RIGHT HEART FAILURE WITH PRESERVED EF 58% 

WITH BERIBERI (DCMP)?

WITH AKI?

WITH HEPATITS SECONDARY TO ISCHEMIA? ,

WITH MODS? 


Day 4( 16/10/20)


No fresh complaints 

Pedal edema - decreased

Investigations:

Hemogram



RFT



O/E : 


Patient is Conscious.

Vitals: 

Febrile - 101F

BP - 120/80 mmhg 

PR - 92 bpm, normal volume , regular

CVS - S1 ,S2 + ,JVP - NORMAL 

RS - BAE + ,NVBS

P/A - Obese, soft , non tender.

CNS - NFND 


Treatment given: 

HEAD END ELEVATIOn

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 2.25MG/IV/QID

INJ THIAMINE  100MG  IN 100ML NS  IV/TID

INJ LASIX ( 40 MG/ IV / TID HR ) IF SBP > 100MMHG

TAB AZITHROMYCIN 500MGPO / OD

NEB WITH MUCOMIST - 6TH HOURLY 

BUDECORT - 12TH HOURLY 

CHEST PHYSIOTHERAPY FOR 4TH HOURLY 

ORAL FLUIDS UPTO 1.5 LIT/DAY 

ALLOW SOFT  DIET 

SYP MUCAINE  GEL 15 ML - 15 MIN BEFORE EACH MEAL 

INJ HEPARIN 5000 / IV / TID


Diagnosis : RIGHT HEART FAILURE WITH PRESERVED EF 58% 

WITH BERIBERI (DCMP)?

WITH AKI?

WITH HEPATITS SECONDARY TO ISCHEMIA? ,

WITH MODS? 


Day 5 (17/10/20)

No fresh complaints 

Pedal edema decreased

Sob decreased

O/E : 


Patient is Conscious,not oriented to time ,place ,person  drowsy but arousable 
Pulpils constricted ( b/l), sluggish to light 

Vitals: 

Febrile - 102F

BP - 110/90 mmhg 

PR - 98 bpm, normal volume , regular

CVS - S1 ,S2 + ,JVP - NORMAL 

RS - BAE + ,NVBS

P/A - Obese, soft , non tender.
Bowel sounds + 

CNS - NFND 

Investigations: 

ABG: 




Treatment given: 

HEAD END ELEVATIOn

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 2.25MG/IV/QID

INJ THIAMINE 100MG IN 100ML NS IV/TID

INJ LASIX ( 40 MG/ IV / TID HR ) IF SBP > 100MMHG

TAB AZITHROMYCIN 500MGPO / OD

NEB WITH MUCOMIST - 6TH HOURLY 

BUDECORT - 12TH HOURLY 

CHEST PHYSIOTHERAPY FOR 4TH HOURLY 

ORAL FLUIDS UPTO 1.5 LIT/DAY 

ALLOW SOFT DIET 

SYP MUCAINE GEL 15 ML - 15 MIN BEFORE EACH MEAL 

CAP . PREGABA- M 75BD

TAB MODAFENIL 200MG OD

SYP.PIRACETIM 5ML BD 

IVF - NS ,RL @ 30ML/HR


Diagnosis : RIGHT HEART FAILURE WITH PRESERVED EF 58% 

WITH BERIBERI (DCMP)?
WITH AKI?( PRE RENAL)

WITH HEPATITS SECONDARY TO ISCHEMIA? ,

Day 6 

Stools not passed 

O/E : 


Patient is Conscious,drowsy but arousable , oriented to person only


Vitals: 

Afebrile 

BP - 120/100mmhg 

PR - 92 bpm, normal volume , regular

CVS - S1 ,S2 + ,JVP - NORMAL 

RS - BAE + ,NVBS

P/A - soft , non tender.
Bowel sounds + 

CNS - NFND 

Investigations: 

Hemogram 



Rft 






Treatment given: 

HEAD END ELEVATIOn

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 2.25MG/IV/QID

INJ THIAMINE 100MG IN 100ML NS IV/TID

TAB AZITHROMYCIN 500MGPO / OD

NEB WITH MUCOMIST - 6TH HOURLY 
BUDECORT - 12TH HOURLY 

CHEST PHYSIOTHERAPY FOR 4TH HOURLY 

ORAL FLUIDS UPTO 1.5 LIT/DAY 

ALLOW SOFT DIET 

SYP MUCAINE GEL 15 ML - 15 MIN BEFORE EACH MEAL 

CAP . PREGABA- M 75BD

TAB MODAFENIL 200MG OD

SYP.PIRACETIM 5ML BD 

IVF - NS ,RL @ 30ML/HR

ALLOW SOFT DIET 

NEOSPORIN POWDER FOR BED SORE
CHANGE POSITION FOR EVERY 4 HOURS

SYP LACTULOSE 30 ML BD , STOP IF>2 EPISODES OF LOOSE STOOLS

OINTMENT SOFRAMYCIN

Diagnosis : RIGHT HEART FAILURE WITH PRESERVED EF 52% 

WITH DCMP SECONDARY TO ALCOHOL ( BERIBERI)
WITH AKI?( PRE RENAL)
WITH URAEMIC ENCEPHALOPATHY?
WITH HEPATITS SECONDARY TO ISCHEMIA? ,

Day 7:

C/o unresponsiveness




O/E : 


Patient is drowsy but arousable , oriented to person only 
Pulpils : nsrl

Vitals: 

Afebrile.

BP - 80mmhg on Inj NORAD @ 12 ML/HR

PR - 130 bpm, normal volume , regular

I/o - 2800/2050 ml

CVS - S1 ,S2 + ,JVP - NORMAL 

RS - BAE + ,NVBS, spo2 - 84% on RA 

P/A - soft , non tender.
Bowel sounds + 

CNS - NOT ORIENTED 

TONE -. UL. LL
         RIGHT. Decreased. Decreased
         LIGHT Decreased Decreased

Power : couldn't be elicited

Bilateral deep tendon reflexes are absent
Plantors are mute  


Investigations:


ECG 




HEMOGRAM




LFT 







ABG




Treatment given: 

HEAD END ELEVATION

IVF - O.45% NS @ 75 ML/HR 
      - RL 

RT FEED - 30ML MILK 2ND HOURLY 
50 ML MILK HOURLY 

INJ PANTOP 40 MG /IV / OD 

INJ PIPTAZ 2.25MG/IV/QID

INJ THIAMINE 100MG IN 100ML NS IV/TID

INJ LASIX ( 40 MG/ IV / BD ) IF SBP > 100MMHG

TAB AZITHROMYCIN 500MGPO / OD

NEB WITH MUCOMIST - 6TH HOURLY 
BUDECORT - 12TH HOURLY 

CHEST PHYSIOTHERAPY FOR 4TH HOURLY 

ORAL FLUIDS UPTO 1.5 LIT/DAY 

ALLOW SOFT DIET 

SYP MUCAINE GEL 15 ML - 15 MIN BEFORE EACH MEAL 

CAP . PREGABA- M 75BD

TAB MODAFENIL 200MG OD

SYP.PIRACETIM 5ML BD 

IVF - NS ,RL @ 30ML/HR

ALLOW SOFT DIET 

NEOSPORIN POWDER FOR BED SORE
CHANGE POSITION FOR EVERY 4 HOURS

SYP LACTULOSE 30 ML BD , STOP IF>2 EPISODES OF LOOSE STOOLS

OINTMENT SOFRAMYCIN

INJ NORAD / 1 AMP ON 20ML NS @12 ML/ HR - TAPER ACCORDINGLY 

INJ DOPAMINE 1AMP IN 20 ML NS @ 2.4 ML/HR

Diagnosis : RIGHT HEART FAILURE WITH PRESERVED EF 52% 

WITH DCMP SECONDARY TO ALCOHOL ( BERIBERI)
WITH AKI?( PRE RENAL)
WITH URAEMIC ENCEPHALOPATHY?
WITH FULMINANT HEPATITS SECONDARY TO ISCHEMIA? ? VIRAL 
WITH HEPATIC ENCEPHALOPATHY

Fever chart

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