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40YR OLD MALE WITH SOB AND PEDAL EDEMA

40YR OLD MALE WITH SOB AND PEDAL EDEMA

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

40 yr old male , driver by occupation presented to the opd with the chief complaints of-
• SOB since 4 days (grade 3-4)
• pedal oedema since 4 days
• cough since 4 days
• abdominal distention since 4 days
• decreased urine output since 4 days even after taking spironolactone.
HOPI:
He was apparently asymptomatic 3yr back.
The patient is a chronic alcoholic and had similar complaints every time he presented to our hospiatl opd partly due to not taking medication and continuing drinking.
Was on intermittent medication of cardivilol.
14/6/2019
He presented with pedal oedema(till knee joint)(pitting type),  decreased urine output and SOB with orthopnea to our opd and was admitted. He was diagnosed with dialated cardiomyopathy( DCMP), mitral regurgitation and ejection fraction of 40% .
Treatment given : ramipril 25mg, lasix 40mg and aldactone50mg.

Time in between:
He visited local RMP every time he had the above symptoms and was using carvedilol and spironolactone for relieving his pedal edema.

20/4/2021
Presented to the opd of our hospital with abdominal distention, SOB, pedal edema since 6 days.
Anasarca was present. Further diagnosed with mitral sub mitral aneurysmal posterior annulus. Treatment given:tab cardivas and dytor plus. Patient refused admission.

8/9/2021 (yesterday)
He had SOB which got aggravated by walking and lying on the bed.
The pedal edema which was till the knee joint was relieved when he had taken spironolactone the day before.
The cough was with sputum which was white in color and non foul smelling.
Abdominal distention not associated with pain.
No history of PND.
Last took alcohol 4days back.

PAST HISTORY:
Not a known case of HTN/ DM.

GENERAL EXAMINATION:
Pt was c/c/c
Afebrile
Clubbing was present
Pedal Edema was present till knee joint.
BP:100/70
PR:85bpm
RR:35cpm
spO2: 95%
Personal history:
Married
Appetite: decreased since 2 days
Non vegetarian
Chronic alcoholic since 23yrs taking 90ml per day.
CVS: S1S2 heard.
Apex beat at 6th intercostal space mid clavicular line.
JVP raised
RS:
P/A:
Abdomen distended
Shifting dullness present
Was given ramipril
Shifted to AMC: 5pm
BP: 80/50
PR: 90
SpO2: 93% RA
Started on lasix infusion 2ml/hr.
7pm
BP: 100/70
PR:95bpm
RR: 37cpm
GRBS:113
SpO2: 95%
INVESTIGATIONS:
RFT: sr cr: 2
Na: 136
K: 3.7
Cl: 100
LFT:  TB- 1.4 ; DB- 0.6; TProtein- 6.4 ; ALB-; SGOT- 115 ; SGPT-89; ALP-214 ; A/G-1.37.
CBP: hb- 14; TLC: 6,300 ; PLT-2.95
Chest Xray

ECG:
   

Usg abdomen
      Mild ascites noted

PROVISIONAL DIAGNOSIS:
Heart failure with mid range ejection fraction and pulmonary  arterial hypertension

SOAP NOTES:
 9/9/2021
S: cough has decreased. Stools passed
O: 
BP: 100/70;
PR: 88bpm;
RR: 31cpm;
SPO2: 96%
A: DCMP,  Cardio renal syndrome( type II), chronic alcoholic, chronic hepatitis
P:
Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascopil D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly

10/9/2021
40yr old male with dialated cardiomegaly in AMC
S: cough arc with sputum, SOB decreased
O: pr c/c/c
Afebrile
BP:100/60mm hg
PR:88bpm
I/O: 700/900
Weight 63kg
GRBS:120
CVS:s1 s2 heard, apex beat in 6th incostal space mid clavicular line, parasternal heave present.
CNS:NAD
RS: NVBS+
P/A:abdomen distended shifting dullness present
A:
DCMP,  Cardio renal syndrome( type II), chronic alcoholic, chronic hepatitis
P:
Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascopil D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly

11/9/2021

SOAP notes:
40yr old male with dialated cardiomegaly in AMC
S: cough ass with sputum, sputum decreased  ,pt drowsy but arousable

O: pt c/c/c
Afebrile
BP:90/80mm hg
PR:88bpm
I/O: 500/200
Weight 63kg
GRBS:113 mg/dl
CVS:s1 s2 heard, apex beat in 6th incostal space mid clavicular line, parasternal heave present, JVP raised
CNS:NAD
RS: NVBS+
P/A:abdomen distended shifting dullness present
A:
DCMP,  Cardio renal syndrome( type II), chronic alcoholic, chronic hepatitis
? Alcohol withdrawal seizures
P:
Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascoryl D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Sup cyproheptadine 5ml /po/TID
Tab lorazepam 2 mg OD
Tab pregabalin 75 mg OD
T Ben XL OD
Inj lorazepam 1/2 amp /slow IV  if seizure episode
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly

13/09/21

S: 
O:
Pt c/c/c 
Drowsy but arousable
BP:90/60
SpO2: 99 @ 7lt O2
PR:86
RR: 36
CVS: CVS:s1 s2 heard, apex beat in 6th incostal space mid clavicular line, parasternal heave present
RS: BAE+ coarse crepts +, decreased sounds in rt IAA,ISA areas 
P/A: Soft, 
Stools not passed
GRBS: 136 mg/dl
2D echo

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