50 yr old M with c/o SOB since 10days

 23/03/2023

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Name: K. Thanmai(intern)

Roll no: 76

Pt came to Medicine OPD with chief complaints of 

Shortness of breath since 10days

HOPI:

Pt was apparently asymptomatic 3months back, later developed SOB of grade IV(NYHA) i.e sob even on minimum physical activity and also on rest.

Since 3-4years patient complains of sob with severe physical activity(grade II) which progressed to current state.

H/o pedal edema and facial puffiness is present

Pedal edema present below knee and of pitting type

H/o decreased urine output,orthopnea,paroxysmal nocturnal dyspnea.

No h/o palpitations,chest pain,sweating,fever,cold

H/o dry cough present since 10days on & off

He got admitted for the above complaints in month of Jan'2023 got treated and discharged.

The previous admission details :

https://39nagarjuna.blogspot.com/2023/01/a-52-year-old-male-with-sob.html?m=1

Consumption of alcohol started 1 week after the discharge and drank half/per day of whiskey. Last binge of alcohol was 5days back.

C/o loss of appetite since 10days and complains that he is feeling abdominal fullness  due to which he doesn't feel like taking food.

H/o vomitings 2 episodes ,non projectile 

PAST HISTORY:

K/c/o Heart failure with reduced EF(36%) with CKD

K/c/o HTN since 3months for which he is using (Tab.HYDRALAZINE 12.5MG PO/OD)

N/k/c/o DM II ,Asthma,TB,epilepsy etc

PERSONAL HISTORY:

Married

Occupation: vegetable seller

diet -mixed

Appetite -loss of appetite since 10days

Sleep- disturbed due to SOB

Burning micturition present, decreased urine output since 5days

Bowel habits regular 

Addictions- half per day of whiskey and stopped drinking 10days back 

 Also eats khaini 

FAMILY HISTORY:

his mother and elder brother died with complaints of severe sob.

GENERAL EXAMINATION:

patient is conscious cooperative coherent well oriented to time place person 

no pallor , icterus, cyanosis,  lymphadenopathy

Clubbing present

Edema of feet present,pitting type,below knee

Vitals 

Temperature : 98.6°F

PR: 86bpm

RR:30cpm 

BP :160/100mmhg 

spo2: 96% at room air 

SYSTEMIC EXAMINATION :

CVS: S1S2 heard,

          JVP Elevated

RS: BAE+, decreased breath sounds in right axillary and infra axillary region

P/A: soft,NT

CNS : 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- Both upper and lower limbs normal

                           Rt        Lt

Power-  UL:     5/5        5/5

                LL.     5/5       5/5

Reflexes          Right      Left

Biceps                 ++        ++

Triceps.              ++.        ++

Supinator           +            +

Knee.                   ++.      ++

Ankle                  ++.       ++

INVESTIGATIONS:

Hb:11g%

TLC:8,200cells/cumm

PLATELET COUNT: 2.82laks/cumm

RBC:3.74

PCV:33.2

CUE:

SUGARS:NIL

ALBUMIN:++++

RBS:81mg/dl

UREA:100

SE.CRETAININE:6.5

SODIUM:134

CHLORIDE:105

POTASSIUM:4.6

IONISED CALCIUM:1.10

LFT:

TB:2.34mg/dl

DB:1.27mg/dl

AKP:515IU/L

TP:5.5gm/dl

ALBUMIN:1.96gm/dl

A/G RATIO:0.6

 

ECG:(23/03/2023)

2D-ECHO:

EF:36%

IVC: Size 1.68cms

All four chambers dilated

Severe TR with moderate PAH(Eccentric TR)

Moderate AR,Mild MR

RWMA,LAD akinetic, RCAZ LCX Hypokinetic,No AS/MS

SEVERE LV SYSTOLIC DYSFUNCTION

DIASTOLIC DYSFUNCTION

REVIEW 2D-ECHO(27/03/23)

EF:41%

IVC: Size 1.95cms,dilated,non collapsing

All four chambers dilated

Severe TR with moderate PAH(Eccentric TR)

Moderate AR, Trivial MR,SCLEROTIC AV

RWMA,LAD akinetic, RCAZ LCX Hypokinetic,No AS/MS

MODERATE LV SYSTOLIC DYSFUNCTION

DIASTOLIC DYSFUNCTION

MINIMAL PE

CHEST X-RAY(PA VIEW)(23/03/2023)

USG-ABDOMEN&CHEST(23/3/23)

IMPRESSION:

1)B/L Pleural effusion (L>R)

2)B/L raised echogenicity of kidneys correlate with RFT

3) Minimal ascitis

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH REDUCED EJECTION FRACTION(36%) SECONDARY TO CAD

HTN SINCE 3MONTHS

B/L PLEURAL EFFUSION (L>R)

 

TREATMENT:

1.FLUID RESTRICTION <1LT/DAY

2.SALT RESTRICTION <2GM/DAY

3.INJ.LASIX 60MG IV/BD

4.INJ.THIAMINE 200MG/IV/TID (in 100ml NS)

5.TAB.METAPROLOL 25MG PO/OD

6.TAB.ECOSPORIN AV 75(10)/PO/HS

7.T.NODOSIS 500MG PO/BD

8.CAP.BIO D3 PO/ONCE WEEKLY

9.PROTEIN RICH DIET 2EGG WHITES/DAY

O2 supplementation if SAT'S<92%