A 60yr old female came with sob


 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box 



 
Chief complaints: 

C/o cold and cough since 6 days.

H/o fall on left shoulder 5days back.

Shortness of  breath since 5days. 

Abdominal distension since 4 days.

Pedal edema since 4 days 


History of presenting illness 

Patient was apparently asymptomatic 6 days back.then she had cold and cough which relieved on medication.  5 days back she fell down from bed while sleeping  at around 5am in morning.  From next day she complaints of breathlessness  which is grade 1 MMRC and progressed to grade 3 MMRC and pedal edema since 4 days. No h/ o fever and headache.   She complaints of left shoulder pain ( due to fall) . No h/ o chest pain ,palpitations, orthopnea, pnd.

Yesterday she went to area hospital around 9am and her bp was 185/120mmhg and then referred to our hospital. On admission her bp was 220/90mmhg.

Past history:

M/k/c/o HTN,DM,TB,Astma, thyroid and epilepsy.

H/o fall from bed  while sleeping 1 year back.

Family history

Not significant.

Personal history:

Patient works as a sweeper at post office 

She takes mixed diet. Her appetite was normal.

Sleep is adequate. Bowel and bladder movements are regular. No addictions 

Drug history: not significant

General examination: 

 patient is conscious coherent and cooperative. Well oriented to time place and person. 

Moderately built and nourished.

Pallor - present 

No icterus  

No cyanosis 

No clubbing 

Oedema:  pitting oedema  ( bilateral pedal oedema) present ( grade 3)  









Vitals:  

On admission 

PR: 98BPM

RR: 24 cycles per min 

BP:  220/100 mmhg 

Temp: afebrile. 

Spo2: 98%

Grbs: 193 mg%  

 Systemic examination :  


CVS: 

S1 , S2 heard 

No thrills 

No  murmurs.

Respiratory system: 

Trachea: central 

Dyspnea: present grade 3 MMRC 

normal vesicular breath sounds heard 

Rales present 


Abdomen : 

Shape : obese (distended) 

No tenderness

No palpable mass

No free fluid , bruits 

Liver palpable ( ? Hepatomegaly) 

Spleen not palpable

Bowel sounds heard 


CNS: 

Patient is conscious 

Speech normal

Memory intact 

Power tone normal ( both upper  and lower limbs) 

No signs of meningeal irritation.

Reflexes : normal.

 PROVISIONAL DIAGNOSIS: 

Heart failure with preserved ejection fraction secondary to hypertensive urgency , 

With denovo Hypertension 

With? Dimorphic anemia. 


Investigations: 



    





 









  2d echo 



  ECG 



USG: 




TREATMENT: 

    14/10/22 




 
O:
Pt c/c/c 
Bp - 120/80mmhg
PR - 74bpm
RR- 22cpm
Temp -98F
Spo2 - 98%
Input- 200ml
Output->400ml

CVS- S1S2 +, S3 @ pulmonary area
RS- BAE+, B/L crepts + (diffuse)
P/A - Obese, soft , nontender 
CNS- HMF intact , No. FND





1) fluid restriction <1.5lit/day
2)salt restriction <2gm/day
3)INJ. Lasix 40mg IV/BD
4)TAB. NICARDIA 10mg /PO/SOS
5)SYP. POTKLOR 15ml IN 1GRAM OF H2O /PO /BD
6) TEMP. &VITAL MONITORING 4th HOURLY 
7)INJ. B12 1000mg IM/OD 




 


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