8.

 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