A 53 year old male with Acute LVF secondary to hypertension with k/c/o CVA, CKD, DM, HTN

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I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

A 53 year old man came to the casuality with 

*chief complaints of:-

-Bilateral pedal edema since 16 days

-Shortness of breath since 10 days

-Decreased urine output since 10 days

-Facial puffiness since 8 days

-Loss of Appetite since 8 days

*History of present illness:-

-Patient was apparently asymptomatic 3 years back after which he developed Right sided Hemiparesis and diagnosed with CVA and was on Antiplatelets on and off. 

-And was diagnosed with Diabetes Mellitus and Hypertension. 

-Complaint of Bilateral pedal edema since 1 and half year and Shortness of breath (Grade 2-3)on and off. 

-And was diagnosed with Chronic Kidney Disease 1 and half year back and on regular medication.No hemodialysis done. 

-shortness of breath:Grade 2- Grade 3,Not associated with Orthopnea/PND since 10 days

-Decreased urine output since 10 days

-Facial puffiness since 8 days 

-Loss of appetite since 8 days 

*Past History:-

Known case of

->Diabetes Mellitus since 3 years and on medication.

->Hypertension since 1and half year and on medication.

->CAD 3 years back and on medication.

*Personal History:-

-Diet:-Mixed

-Appetite:-lost

-Micturition:-Abnormal

-Bowel movements:-Regular

-No allergies

-Addictions:-Alcoholic since 20 years(regular),stopped 3 years back.

*Family History:-

Insignificant

*General Examination:-

Patient is conscious,coherent and non cooperative. 

He is well built and well nourished.

-Vitals:-

Temp:-97.5

PR:-98/min

RR-27/min

BP:-160/90mm/Hg

SpO2:-98% at Room air

GRBS:-184 mg/dl

-physical examination:-

Pallor : not present

icterus : not present

cyanosis : not present

clubbing : not present

lymphadenopathy : not present

pedal edema : present,pitting type

*Systemic Examination:-

-CVS:-

S1 and S2 are heard

no thrills and no murmurs

-Respiratory:-

vesicular breath sounds heard

trachea is in central position

wheezing:- present

dyspnoea:-Grade2-Grade3

Adventitious sounds:-Crepts heard

-Abdomen:-

Distended abdomen

no tenderness

no palpable mass

no hernial orifices

free fluid :- present

liver and spleen are not palpable

bowel sounds are heard

Genitals:-scrotal swelling is present.

-CNS:-

Conscious and normal speech

normal gait

crainal nerves are normal

sensory system is normal

motor system is normal

-Reflexes:-

              right       left

biceps     +2         +2

triceps     +2        +2

supinator +2         +2

knee         +2          +2

ankle         +2         +2

*Provisional Diagnosis:-

Acute Left Ventricular Failure on Chronic heart failure(secondary to CAD) 

with k/c/o CKD, CVA, DM, HTN 

with Right sided pleural effusion (transudative) with Refractory Metabolic Acidosis and Refractory Hyperkalemia.

*Investigations:-

ECG:-

HIV:-

HbsAg:-

HCV:-

Serum Uric Acid:-

Serum Electrolytes:-

Serum Creatinine:-

Liver Function Tests:-

Glycated Heamoglobin:-

Blood Urea:-

Random Blood Sugar:-

Hemogram:-

*Chest X-Ray:-

Right sided pleural effusion with consolidation

*USG:-

*2D echo:-

**2 Sessions of Hemodialysis done. 

**Pleural tap done I/v/o Right sided gross plueral effusion

*Treatment:-

On 8/11/2021:-

1.Fluid restriction <1lit/day

2.Salt restriction <2gm/day

3.Inj.Lasix 40mg/IV/stat followed by Inj.Lasix 20mg @2.5ml/hr

4.Inj.Pantop 40mg/IV/OD

5.Inj.Zofer 4mg/IV/SOS

6.Nebulization with budecort and duolin-8th hourly. 

7.Tab.Ecosprin AV (75/20)/Po/H/S

8.Tab.Amlong 10mg /Po/H/S

9.Inj.HAI s/c premeal acc to sliding scale

10.weight monitoring daily

11.Tab.Nodosi 550mg/po/od

12.GRBS -4th hourly

13.Vitals-2nd hourly

Foley's catheterization done.

On 9/11/2021:-

1.Fluid restriction <1lit/day

2.Salt restriction <2gm/day

3.Inj.Lasix 40mg/IV/stat followed by Inj.Lasix 20mg @2.5ml/hr

4.Inj.Pantop 40mg/IV/OD

5.weight monitoring daily

6.Nebulization with budecort and duolin-8th hourly. 

7.Tab.Ecosprin AV (75/20)/Po/H/S

8.Tab.Amlong 10mg /Po/H/S

9.Inj.HAI s/c premeal acc to sliding scale

10.Tab MET-Xl 50mg/PO/OD

11.Tab.Metlazone 10mg/PO/BD

12.Tab.Nodosi 550mg/po/od

13.Inj.Erythropoetin 

14.Inj.Iron sucrose 1Amp in 100 ml NS/IV/OD

15.Inj.Sodium bicarbonate 50ml/IVstat followed by 50ml/IV/in 100 ml NS/IV stat

16.Inj.Calcium gluconate 1 amp/10cc/IVstat slowly in 10 mins.

On 10/11/2021:-

1.Fluid restriction <1lit/day

2.Salt restriction <2gm/day

3.Inj.Lasix 40mg/IV/stat followed by Inj.Lasix 20mg @2.5ml/hr

4.Inj.Pantop 40mg/IV/OD

5.Tab.Ecosprin AV (75/20)/Po/H/S

6.Tab.Amlong 10mg /Po/H/S

7.Inj.HAI s/c premeal acc to sliding scale

8.Tab MET-Xl 50mg/PO/OD

9.Tab.Metlazone 10mg/PO/BD

10.Inj.Erythropoetin 

11.Inj.Iron sucrose 1Amp in 100ml NS/IV/OD

12.Weight monitoring daily

13.Monitor vitals -2nd hourly

14.Tab shelcal PO/OD

15.Nebulisation with budecort and duolin-8th hourly

11/11/2021:-

1.Fluid restriction <1lit/day

2.Salt restriction <2gm/day

3.Inj.Lasix 40mg/IV/stat followed by Inj.Lasix 20mg @2.5ml/hr

4.Inj.Pantop 40mg/IV/OD

5.Tab.Ecosprin AV (75/20)/Po/H/S

6.Tab.Amlong 10mg /Po/H/S

7.Inj.HAI s/c premeal acc to sliding scale

8.Tab MET-Xl 50mg/PO/OD

9.Tab.Metlazone 10mg/PO/BD

10.Inj.Erythropoetin 

11.Inj.Iron sucrose 1Amp in 100ml NS/IV/OD

12.Weight monitoring daily

13.Monitor vitals -2nd hourly

14.Tab shelcal PO/OD

15.Nebulisation with budecort and duolin-8th hourly