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A 48 yr old male with heart failure.

 


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

CHIEF COMPLAINT:-

A 48 year-old man (driver by occupation)came to the hospital with complaints of :- 

Bilateral Pedal edema since 1 month.

Shortness of breath since one week and aggrevated at 1:30 am on 19/12/2021.

Productive cough since 2-3 days. 


HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 1 month ago when he noticed swelling in both his legs which was gradually progressive, extending to his knees.

 H/o increased shortness of breath since 1 day which aggravated to Grade 4 SOB since 2 hours from 1:30 am on 19/12/21,a/w orthopnea and PND.

 H/o Productive cough since 2-3 days with sputum.

H/o of cold since one week.

H/o of weight gain around 7 kg in last one month .

No H/o decreased urine output. 

No H/o facial puffiness.

 No h/o fever.


PAST HISTORY:-

He is not a k/c/o DM, HTN, TB, Asthma, EPILEPSY.


PERSONAL HISTORY:-

Diet- Mixed. 

Appetite- Normal

Sleep - Decreased

Bowel and bladder movements - Regular.

He smokes 3-4 cigarettes a day since the past 16 years. 

He consumes 90 ml of alcohol once every month .

He quit smoking since last 3 months.


FAMILY HISTORY:-

No similar complaints were observed in the family members.


GENERAL EXAMINATION:-

Patient is consious, coherent, cooperative and well oriented to time and place.

Bilateral, pitting type of pedal edema present. 

No signs of Pallor, icterus, clubbing, cyanosis lymphadenopathy. 

Vitals:-Temp: 97.3 F

             Bp: 100/60 mm Hg

             Pr: 105 bpm

             Rr: 25cpm

             Grbs: 206 mg/dl

             SpO2 at room air : 83%


SYSTEMIC EXAMINATION:-

CVS:
Inspection-Raised jvp
Palpation-No pericardial bulge is seen.
Auscultation:- S1 and S2 heard
                         Apex beat-1-2 cm lateral to                               the mid clavicular line heard                             in 6th intercostal space.
RS: BAE +, ISA and IAA inspiratory crepts +,         B/L ISA Wheeze +

P/A: soft , non tender
CNS: NAD



CLINICAL IMAGES:-

B/L pitting edema 



Chest x-ray AP view


ECG





USG report







PROVISIONAL DIAGNOSIS:-
EXACERBATION OF COPD
HEART FAILURE 
COMMUNITY AQUIRED PNEUMONIA
B/L MILD PLEURAL EFFUSION 

Treatment :
INJ. LASIX 80 mg IV stat
Inj .Pantop 40 mg iv stat
Tab Ecospirin 75/20mg PO OD
Bp/PR monitoring 2nd hrly.
Nebulization 


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