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%
