60 YEAR MALE WITH SOB
A 60 yr old male who is daily wage labourer by occupation came to the hospital with chief complaints of SOB since 10 days, decreased urine output since 10days , abdominal distension since 10 days and
left lower limb pain since yesterday night.
He was admitted on 17/11/21 with us for 1 week with DCMP secondary to CAD.(EF = 28 %)
HOPI
Pt was apparently asymptomatic 2months back then patient complains of pedal edema since 2 months , progressed to above knees
with decreased urine output since 15days and break in the stream of urination
.C/o chest pain on and off since 15 days ,not radiating,not a/w sweating or giddiness.
SOB,sudden onset,progressed from grade 2 - grade 4 a/w orthopnea and PND.
Then on 28/1/22, he came with complaints of grade 4 sob and constipation since 10 days.
PAST HISTORY
Pt is diabetic and is on Tab Glimperide 1mg plus Metformin 500mg OD since 5 yrs.
H/O CVA 20 yrs back
H/o poliomyelitis in childhood
personal history:
appetite-normal
bowel movements-regular
micturition - normal
addictions- alcoholic 1-2 times /week (90ml ) since 10 yrs
smoking: 1 pack/day (10/day) - beedi since 10 yrs
On General Examination:
Patient is conscious,non coherent,not Cooperative and not oriented to time, place and person
no signs of pallor ,icterus,cyanosis , clubbing, lymphadenopathy
Edema of feet-B/L(pitting type)
Deformity in right foot
Vitals :
BP : 110/70mm Hg
PR : 99bpm
RR : 26cpm
SpO2 : 98%
Systemic Examination-
CVS
Inspection-
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line
Palpation-
Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line
Percussion-
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Increased respiratory rate noted
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the sixth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
Bilateral basal crepts noted in infra axillary area and infra mammary area
P/A-
Distended abdomen
Soft, non tender
CNS-
NAD
Investigations:
18/11/21
2d echo
Chest X ray
Investigations :
18/11/21
28/1/22
Hb - 12.7
TLC - 10,300
Plt - 1.7 lakhs
Urea - 53(12-42)
Creatine - 1.9
Na+ - 134
K+ - 3.2
Cl- - 97
Total bilirubin - 3.64(0-1)
Direct bilirubin - 1.98(0-0.2)
Total protein - 6.3
SGOT - 229
SGPT - 87
RBS - 76 (100-160)
ABG -
pH - 7.53
pCO2 - 27.9
pO2 - 61.6
Hco3 - 26.2
ECG:
28/1/22
29/1/22
8.30am
11.40am
30/01/22
Heartfailure with reduced ejection fraction (ef)28% secondary to CAD with DCMP
Treatment
1)Head end elevation
2)O2 inhalation to maintain SpO2 >92%
3)Inj. Lasix infusion @5ml/hr
4)Inj. Pantop 40mg/IV/OD
5)Nebulization with -Budecort 8th hrly
-Ipravent 6th hrly
6)Tab. Metalazone 5mg
7)Tab. Ecospirin AV (75/20mg)ug
8) Inj. Dobutamine 6ml/hr
9) Inj. Zofer 4mg/IV/TID
10) Syp. Lactulose 10ml
11) Tab. Ramipril 2.5mg
12) Tab. Carvediol 3.125 mg
13) fluid restriction <1l/day
14) salt restriction < 2g/day
