Case History and Clinical Findings
A 86 YR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF IRRELAVANT TALK AND AKTERED MENTAL STATUS SINCE 10 DAYS
COMPLAINTS OF SHORTNESS OF BREATH SINCE 3 DAYS
COMPLIANTS OF COUGH SINCE 3 DAYS
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO AND THEN SHE DEVELOPED
ALTERED MENTAL STATUS ON AND OFF AND HER SPEECH WAS INCOHERENT AT TIMES
AND BECOMING NORMAL ON HER OWN.
EACH EPISODE LASTED 10 MINS
COUGH WAS PRODUCTIVE TYPE 2 DAYS AGO WITH WHITE SPUTUM'MUCOID CONSISTENCY
AND SCANTY IN AMOUNT , NOW IT IS OF DRY TYPE
SHE ALSO HAD SHORTNESS OF BREATH WHICH WAS GRADE III INITILLY AND THEN
PROGRESED TO GRADE IV FOR WHICH SHE WENT TO LOCAL HOSPITAL AND ECHO WAS
DONE- CAD (LAD TERRITORY) GLOBAL HYPOKINESIA, SEVERE LV DYSFUNCTION
NO H/O OTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNOEA , PALPITATIONS, CHEST PAIN,
GIDDINESS
PAST ILLNESS:
NOT A KNOWN CASE OF HTN, DM, CVA, ASTHMA,EPILEPSY, TB
PERSONAL HISTORY:
DIET- MIXED
APPETITE- DECREASED
BOWEL AND BLADDER MOVEMENTS- REGULAR
SLEEP- ADEQUATE
ADDICTIONS- NONE
ON EXAMINATION AT ADMISSION:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA
BP- 90/50MMHG
PR- 85BPM
RR-24CPM
SPO2- 88%@RA 95% ON 8L OF O2
GRBS- 126MG/DL
CVS-S1 S2 +
RS- BAE+, B/L BASAL CREPTS HEARD
PA- SOFT NON TENDER
CNS- NFD
ON EXAMINATION AT DISCHARGE:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
BP- 90/50MMHG
PR- 72BPM
SPO2- 98%@RA
GRBS- 82MG/DL
CVS-S1 S2 +
RS- BAE+, B/L BASAL CREPTS HEARD, RT IAA CREPTS +, BRONCHIAL BREATH SOUNDS +
PA- SOFT NON TENDER
CNS- NFD
BRIEF COURSE IN HOSPITAL-ON DAY 1 PATIENT PRESENTED WITH ABOVE COMPLAINTS
WAS INITIALLY CONSCIOUS, COHERENT AND COOPERATIVE .AT THE TIME OF ADMISSION
HER BP WAS 90/50 WITH OUTSIDE ECHO SHOWING CAD(LAD TERRITORY) WITH GLOBAL
HYPOKINESIA AND SEVERE LV DYSFUNCTION.THEN DIURETICS AND ANTIPLATELETS
WERE STARTED.MONITORING HER BP AND CARDIOLOGY CONSULTATION WERE TAKEN ON
3/2/23 I/V/O CORONARY ARTERY DISEASE AND CARDIOLOGIST ADVICED INJ.HEPARIN 4000
IU/IV/BD AND TAB.CAVERDILOL 3.125 MG WAS ADVICED AND ADVICE FOLLOWED AND HER
SODIUM AND POTASSIUM LEVELS FOUND TO BE LOW AND ORAL POTASSIUM
SUPPLIMENTATION WAS GIVEN AND HER TRUE HYPONATREMIA WAS ATTRIBUTED TO
?SIADH. AS HER CHEST X RAY SHOWED MIDDLE LOBE CAVITY OF RT.LUNG USG CHEST
WAS DONE WHICH SHOWED BILATERAL PLEURAL EFFUSION(TAP NOT DONE).ON 3/2/23
OPTHALMOLOGY REFERRAL WAS DONE I/V/O RAISED ICT FEATURES AND ADVICE
FOLLOWED ON 4/2/23 PULMONOLOGY REFERRAL WAS DONE I/V/O X RAY CHANGES AND
ADVICE FOLLOWED.ON 3/2/23 PT MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED AND
WAS STARTED ON INJ.NORAD AND ADJUSTED ACCORDING TO HER BP .X RAY REPORTING
WAS DONE AND SHOWED BILATERAL LUNG CONSOLIDATION WITH MILD
CARDIOMEGALY.PATIENT WAS IRRITABLE DUE TO ?ICU PSYCHOSIS AND ANXIOLYTICS
WERE GIVEN.NEXT DAY AS HER MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED
INJ.DOBUTAMINE 250 MCG IN 50ML NS WAS STARTED AND TAPERED AS HER BP
IMPROVEDPATIENT WAS ADEQUATELY TREATED.PATIENT CONDITION IMPROVED AND
DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION.
Investigation
USG ABDOMEN-NAD
USG CHESTRIGHT MILD PLEURAL EFFUSION
HEMOGRAM ON 3/2/23
HB- 10.7 GM/DL
TLC- 10,300 CELLS/CUMM
PLATELETS- 3.77 LAKHS/CUMM
N/L/E/M/B- 74/16/01/09/00
PCV- 32.3 VOL%
MCV- 85.7 FL
MCH- 28.4 PG
MCHC- 33.1%
RBC- 3.77
IMPRESSION- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE
HEMOGRAM ON 8/2/23
HB- 9.9 GM/DL
TLC- 5700 CELLS/CUMM
PLATELETS- 3.27 LAKHS/CUMM
N/L/E/M/B- 57/26/02/15/00
PCV- 31.4 VOL%
MCV- 88 FL
MCH- 27.7 PG
MCHC- 31.5%
RBC- 3.57
IMPRESSION- NORMOCYTIC NORMOCHROMIC ANEMIA WITH MONOCYTOSIS
2DECHOESD- 5.44CMS
EDD- 6.3CM
DPW- 1CM
EF- 30%
FS- 15%
SEVERETR WITH PAH, MILD MR/AR
GLOBAL HYPOKINETIC
NO AS/MS
SCLEROTIC AV
MODERATE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION
REVIEW 2D ECHO ON 6/2/23
GLOBAL HYPOKINETIC
MODERATE TR WITH PAH, MILD MR, MODERATE AR
NO AS/MS, SCLEROTIC AV
EF=30
MODERATE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION
IVC SIZE COLLAPSING
MILD DILATED LA/LV
DILATED RA.RV
NO PAH/PE
Diagnosis HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CORONARY ARTERY DISEASE(EF 30%) WITH ANTERIOR WALL MI WITH TRUE HYPONATREMIA SECONDARY TO SIADH(RESOLVED) AND HYPOKALEMIA (RESOLVED) WITH BILATERAL LUNG CONSOLIDATION
Treatment Given(Enter only Generic Name)
T. ECOSPRIN GOLD PO HS [75/75/10 MG]
T. MET XL 25MG PO OD
INJ LASIX 20MG IV BD
INJ NORAD DS 2AMP IN 46ML NS IV @ 6ML/HR
FLUID RESTRICTION
O2 SUPLEMENTATION TO MAINTAIN SPO2>94%
Advice at Discharge
T. ECOSPRIN GOLD 75/75/10 MG PO/HS
T.DYTOR 5MG PO/OD 9AM--*--*
T.CARDIVAS 3.125MG PO/OD 8AM--*--*
FLUID RESTRICTION <1LTR/DAY
Follow Up
REVIEW TO GM OP AFTER 1 WEEK/SOS
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