A 63 Y/O MALE WITH PEDAL EDEMA SHORTNESS OF BREATH AND SCROTAL SWELLING

CHIEF COMPLAINTS

Pedal edema since 3 months 

Shortness of breath since 3 months[grade 2 to grade 3]

Scrotal swelling since 1 month

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 months back then he developed b/l pedal edema(pitting type) for which he went to near by RMP and got medication

Following which he had shortness of breath (grade 2 to grade 3)

No c/o Orthopnea, PND, chest pain, Palpitations

C/o Scrotal swelling (painless) 

HISTORY OF PAST ILLNESS

Not a known case of DM

Not a known case of HTN

Not a known case of Asthma

Not a known case of TB

Treatment history:

Not significant

Personal history:

Diet: Mixed 

Appetite: Normal

Bowel & Bladder: Regular

Addictions: Alcoholic since 25 years

Non-smoker

Family history:

Not significant

General examination:

NO Pallor

NO icterus

NO cyanosis

NO clubbing

NO lymphadenopathy

Edema of feet: present (b/l up to knee)

VITALS

BP: 80/60 mm/hg

PR: 98bpm, irregular

SpO2: 96% on RA

GRBS: 142mg%

SYSTEMIC EXAMINATION

CVS

S1,S2 Heard, no thrills and murmurs

JVP increased



Apex best:7th intercostal space(lateral and outward to midclavicular line)

Parasternal heave present (grade 2)

Respiratory

NVBS heard

Dyspnea present (grade 3 to grade 4)

Abdomen:

Shape of abdomen: Scaphoid

Tenderness: present in Rt Hypochondrium

CNS:

NAD

Provisional diagnosis:

HF with rEF with EF~20%

 DCMP with Global Hypokinesia

(?) Persistent A.Fibrillation with RVR

INVESTIGATIONS

ECG


COMPLETE URINE TEST

HEMOGRAM

TREATMENT

31-07-21

IV was given

HFvEF [EF=20%]

Dcmp i GLOBAL HYPOKINESIA

VITALS 

Afebrile

BP :80/60 mm Hg

PR = 114 beats/min IRREGULAR

CVS = S1 S2 +

RS = BAE + clear

GRBS : 133 mg/dl

P/A : soft


1] PROPPED UP POSTURE

2] INJ. LASVX 40 mg IV/BD

3]TAB MET 12.5mg PO/BD

4]FLUID RESTRICTION < 1 L/ DAY

5] SALT RESTRICTION < 2mg/DAY

6] TAB RAMIPRIL 2.5mg 

7]TAB ELOSPIRIN [75/40] POLLS

8]INJ THIAMINE 200mg IV 100 ml NS/IV/OD

9] SYP. CREMAFFINE 15ml 

9] BP/PR/SP O2 CHARTING AND HOURLY

10]STRICT I/O CHARTING

11] GRBS CHARTING

12] O2 INHALATOR IF SPO 2  < 99%


01-08-2021

IV was given

HFvEF [EF=20%]

Dcmp i GLOBAL HYPOKINESIA

VITALS 

Afebrile: 98.6 Farenhiet

BP :80/60 mm Hg

PR = 82 beats/min

CVS = S1 S2 +

RS = BAE + clear

GRBS : 133 mg/dl


1] PROPPED UP POSTURE

2] INJ. LASVX 40 mg IV/BD

3]TAB MET 12.5mg PO/BD

4]FLUID RESTRICTION < 1 L/ DAY

5] SALT RESTRICTION < 2mg/DAY

6] TAB RAMIPRIL 2.5mg 

7]TAB ELOSPIRIN [75/40] POLLS

8]INJ THIAMINE 200mg IV 100 ml NS/IV/OD

9] BP/PR/SP O2 CHARTING AND HOURLY

10]STRICT I/O CHARTING

GRBS CHARTING

12] O2 INHALATOR IF SPO 2  < 99%


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