Case 43 56 female with sob since 1 month

Doa 26/8/24

Dod 28/8/24

Diagnosis

HEART FAILURE WITH REDUCED EF [36%} SECONDARY TO CAD

CAD - ACS - NSTEMI - AWMI

COMMUNITY ACQUIRED PNEUMONIA

K/C/O HTN SINCE 4 YEARS

K/C/O DM - II SINCE 4 YEARS

H/O CVA - LEFT HEMIPARESIS 4 YEARS AGO

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O BREATHLESSNESS SINCE YESTERDAY

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 DAY AGO THEN SHE DEVELOPED

BREATHLESSNESS, SUDDEN ONSET, GRADUALLY PROGRESSIVE, ASSOCIATTED WITH

ORTHOPNEA

H/O NO URINE OUTPUT SINCE YESTERDAY NIGHT

H/O INCREASED FREQUENCY OF MICTURITION SINCE 2 YEARS ASSOCIATED WITH

INCOMPLETE EVACUATION

H/O PEDAL EDEMA

NO H/O ABDOMINAL DISTENSION,

NO H/O FEVER, COLD, COUGH

NO H/O CHEST PAIN, PALPITATIONS

NO H/O BURNING MICTURITION

NO H/O SIMILAR COMPLAINTS IN PAST

PAST HISTORY:

K/C/O HTN SINCEE 4 YEARS ON TELMA 40 MG PO OD

K/C/O DM - II SINCE 4 YEARS ON GLIMI - M1 PO OD

H/O OF CVA - LEFT HEMIPARESIS 4 YEARS AGO ON TAB. ASPIRIN + CLOPIDOGREL

N/K/C/O EPILEPSY, THYROID DISORDER, CAD, ASTHMA

PERSONAL HISTORY :

DIET - MIXED

APPETITE - NORMAL

SLEEP - ADEQUATE

BOWEL MOVEMENTS - REGULAR

BLADDER MOVEMENTS - INCREASED MICTURION

ADDICTIONS - NONE

FAMILY H/O- NOT SIGNIFICANT

GENERAL EXAMINATION:

PT IS C/C/C

NO VISIBLE SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,

PEDAL EDEMA

TEMP: 98 F

PR: 112 BPM

RR: 42 CPM

BP: 150/100 MM HG

SPO2: 75% @ RA, 85% 10 LIT. OXYGEN

GRBS: 280 MG%

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD, NO MURMURS

CNS: NFND

RS: BAE+, NVBS

CREPTS - PRESENT

P/A: SOFT, NON TENDER

CARDILOGY REFERRAL DONE ON 27/8/24 I/V/O ECG AND 2D ECHO CHANGES

ADVISED

TAB. ALDACTONE 25 MG PO/OD

TAB. METXL 25 MG PO/OD

PLAN CAG AFTER MEDICAL STABILISATION

COURSE IN THE HOSPITAL :A 60 YR OLD FEMALE KNOWN HYPERTENSIVE AND DIBETIC

WAS BROUGHT TO CASULTY WITH C/O BREATHLESSNESS SINCE 1 DAY PATIENT WAS

EVALUATED AND FOUND TO HAVE HEART FAILURE WITH REDUCED EF , TROPONIN I WAS

ELEVATED - 12800 AND TREATMENT WAS STARTED WITH DIURITICS ,ARBS ,BETA

BLOCKERS ANTICOAGULENTS AND INTERMITTENT CPAP ON DAY 2 OF ADMISSION ECG

CHANGES WERE NOTED -DEEP INVERTED T WAVES IN V1-V6,II,AVL.CARDIOLOGIST DR

SHIVAPRASAD OPINION WAS TAKEN I/V/O NEW ONSET ECG CHANGES AND ADVISED FOR

CORONARY ANGIOGRAM AFTER STABILISATION WITH METIONED TREATMENT

,PULMONARY EDEMA RESOLVED,PATIENT IMPROVED CLINICALLY,SO PATIENT IS BEING

REFERRED I/V/O CORONARY ANGIOGRAM AND FURTHER CARDIOLOGIST INTERVENTION

Investigation

COMPLETE URINE EXAMINATION (CUE) 26-08-2024 11:08:AM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

HBsAg-RAPID Negative

Anti HCV Antibodies Non Reactive

RFT 26-08-2024 11:08:AM

UREA 24 mg/dl 42-12 mg/dl

CREATININE 0.8 mg/dl 1.1-0.6 mg/dl

URIC ACID 2.7 mmol/L 6-2.6 mmol/L

CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 4.0 mg/dl 4.5-2.5 mg/dl

SODIUM 129 mmol/L 145-136 mmol/L

POTASSIUM 5.1 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 91 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 26-08-2024 11:08:AM

Total Bilurubin 0.74 mg/dl 1-0 mg/dl

Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 55 IU/L 31-0 IU/L

SGPT(ALT) 13 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 162 IU/L 141-53 IU/L

TOTAL PROTEINS 7.6 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.94 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.08

SERUM ELECTROLYTES (Na, K, C l) 26-08-2024 10:49:PM

SODIUM 135 mmol/L 145-136 mmol/L

POTASSIUM 4.2 mmol/L 5.1-3.5 mmol/L

CHLORIDE 94 mmol/L 98-107 mmol/L

hemogram 26/8/24

HAEMOGLOBIN 11.7 gm/dl

TOTAL COUNT 11,000 cells/cumm

NEUTROPHILS 53 %

LYMPHOCYTES 36 %

EOSINOPHILS 01 %

MONOCYTES 10 %

BASOPHILS 00 %

PCV 33.3 vol %

M C V 82.2 fl

M C H 28.9 pg

M C H C 35.1 %

RDW-CV 13.1 %

RDW-SD 39.7 fl

RBC COUNT 4.05 millions/cumm

PLATELET COUNT 2.3 lakhs/cu.mm

RBC Normocytic normochromic

WBC With in normal limits

PLATELETS Adeqaute

HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic

E S R 35 mm/ 1 st hour

SERUM LIPIDS

Total Cholesterol 167 mg/DL

Triglycerides 93 mg/dl

HDL Cholesterol 32.5 mg/dl

LDL Cholesterol 95.2 mg/dl.

VLDL * 18.6 mg/dl

FBS 205 mg/dl

HbA1c 7.0 %

USG ON 26/8/24

FINDINGS

E/O FREE FLUID NOTED IN RIGHT PLEURAL SPACE WITH UNDERLYING AIR SONOGRAMS

E/O 30 MM HYPERECHOIC FOCI NOTED IN GALL BLADDER

IMPRESSION

RAISED ECHOGENECITY OF RIGHT KIDNEY

RIGHT PLEURAL EFFUSION WITH UNDERLYING CONSOLIDATION

CHOLELITHIASIS

2D ECHO ON 26/8/24

RWMA (+) LAD TERRITORY AKINETIC

MILD MR + (MR JET AREA 2.82 CM2) (ECCENTRIC MR +)

MILD AR+ (AR - PHT - 506 M/SEC)

MILD TR+ WITH PAH (RUSP, 33+10=43 MMHG) (ECCENTRIC TR+)

MAC; CALCIFIED AV; NO AS/MS

EF = 36 % SEVERE LV DYSFUNCTION +

GRADE I DIASTOLIC DYSFUNCTION +

NO PE/LV CLOT

DILATED LA/LV

IVC SIZE (1.7CMS)

IVS - 1.15CMS, ESD - 5.45 CMS, EDD - 6.66 CMS, DPW - 1.15 CMS

ABG 27-08-2024 05:46:AM

PH 7.466

PCO2 34.6

PO2 55.0

HCO3 24.7

St.HCO3 25.8

BEB 1.9

BEecf 1.3

TCO2 46.5

O2 Sat 88.5

O2 Count 20.0

HEMOGRAM 27/8/24

HAEMOGLOBIN 13.1 gm/dl

TOTAL COUNT 13,500 cells/cumm

NEUTROPHILS 64 %

LYMPHOCYTES 28 %

EOSINOPHILS 01 %

MONOCYTES 07 %

BASOPHILS 00 %

PCV 36.4 vol %

M C V 80.8 fl

M C H 28.8 pg

M C H C 36.0 %

RDW-CV 12.9 %

RDW-SD 37.6 fl

RBC COUNT 4.55 millions/cumm

PLATELET COUNT 2.44 lakhs/cu.mm

RBC Normocytic normochromic

WBC Increased on smear

PLATELETS Adeqaute

HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic bloodpicture with leucocytosis

SERUM ELECTROLYTES 27/8/24

SODIUM 135 mmol/L

POTASSIUM 4.2 mmol/L

CHLORIDE 94 mmol/L

CALCIUM IONIZED 1.28 mmol/L

TROPONIN - I -

26/8/24 12800

28/8/24 4486

hemogram 28/ 8/24

HAEMOGLOBIN 11.7 gm/dl

TOTAL COUNT 11,000 cells/cumm

NEUTROPHILS 53 %

LYMPHOCYTES 36 %

EOSINOPHILS 01 %

MONOCYTES 10 %

BASOPHILS 00 %

PCV 33.3 vol %

M C V 82.2 fl

M C H 28.9 pg

M C H C 35.1 %

RDW-CV 13.1 %

RDW-SD 39.7 fl

RBC COUNT 4.05 millions/cumm

PLATELET COUNT 2.3 lakhs/cu.mm

RBC Normocytic normochromic

WBC With in normal limits

PLATELETS Adeqaute

HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic

SERUM ELECTROLYTES 28/8/24

SODIUM 139 mmol/L

POTASSIUM 3.1 mmol/L

CHLORIDE 102 mmol/L

CALCIUM IONIZED 1.17 mmol/L

SERUM MAGNESIUM 1.7 mg/dl 28/8/24

Treatment Given(Enter only Generic Name)

INTERMITENT CPAP

FLUID RESTRICTION LESS THAN 2 LITRES/DAYS

SALT RESTRICTION LESS THAN 2 GM /DAY

INJ. LASIX 60 MG IV STAT

INJ. AUGMENTIN 1.2 GM IV TID

TAB. AZITHROMYCIN 500 MG PO OD

INJ. LASIX 40 MG IV BD (IF SBP >= 110 MMHG)

TAB ALDACTONE 25 MG PO OD

TAB. TELMA 40 MG PO OD

INJ. HAI S/C TID ACCORDING TO GRBS

TAB. CLOPIDOGREL 75 + ASPIRIN 20 MG PO HSI

INJ. LASIX 100 MG IN 50 ML NS @ 3 ML/HR

INJ. HEPARIN 5000IU IV TID

TAB. ECOSPRIN GOLD 75/75/20 PO HS

TAB. MET-XL 12.5 MG PO OD

SYP. POTCHLOR 10ML PO TID

INJ. KCL 2 AMP IN 500 ML NS IV OVER 5 HOURS

GRBS 7. PROFILE

14) MONITOR VITALS

Advice at Discharge

PATIENT AND PATIENT ATTENDERS WERE EXPLAINED ABOUT THE PATIENT CONDITION IN

THEIR OWN UNDERSTANDABLE LANGUAGE THAT PATINET IS DIAGNOSED WITH

HEART FAILURE WITH REDUCED EF [36%} SECONDARY TO CAD

CAD - ACS - NSTEMI - AWMI

COMMUNITY ACQUIRED PNEUMONIA

K/C/O HTN SINCE 4 YEARS

K/C/O DM - II SINCE 4 YEARS

H/O CVA - LEFT HEMIPARESIS 4 YEARS AGO

PATIENT AND PATIENT ATTENDERS WERE EXPLAINED ABOUT THE RISK ASSOCIATED LIKE

SUDDEN CARDIC DEATH

CARDIOLOGIST DR SHIVAPRASAD OPINION WAS TAKEN I/V/O NEW ONSET ECG CHANGES

AND ADVISED FOR CORONARY ANGIOGRAM WHICH WAS EXPLAINED AND AGREED BY

PATIENT ATTENDERS

SO PATIENT IS BEING REFERRED I/V/O CORONARY ANGIOGRAM AND FURTHER

CARDIOLOGIST INTERVENTION

HOSPITAL STAFF AND DOCTORS ARE NOT RESPONSIBLE FOR ANY UNTOWARD EVENTS

THAT OCCUR FURTHER

Follow up in december 2024

Pateint expires at home