40YR OLD MALE WITH SOB AND PEDAL EDEMA

 

40YR OLD MALE WITH SOB AND PEDAL EDEMA

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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

Day1

Day 2

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

13/9/21

S

C/o breathlessness

O

Pt is drowsy but arousable

PR - 86 /min , regular

RR- 36 /min

SPO2 99% @ 7 LTRS /MIN

BP - 90/60 mmHg- on inotropes

RS - BAE+ COARSE CREPTS + , ↓AE on R IAA, ISA area +

CVS - APEX- 6 TH ICS outside MCL, parasternal heave +

P/A soft 

Stools - not passed

GRBS - 136 mg/dl

A

DCMP with ALCOHOLIC HEPATITIS

CARDIORENAL SYNDROME

METABOLIC ACIDOSIS

ALCOHOL WITHDRAWAL SYNDROME

? PULMONARY EMBOLISM

P

Oxygen inhalation 7 ltr/min to max SpO2 98%

Head end elevation

Fluid restriction < 1.5 ltrs per day

Salt restrictions to < 2 gm/day

RT feeds - 200 ml milk + protein powder/2nd hrly

Plain water 100ml/hrly

INJ NORADRENALINE @ 17 ml/hr ↑/↓ to maintain MAP > 65

INJ DOUBUTAMIN @ 10 ml /hr

INJ LASIX 40 mg in 10 ml/ NS INFUSION @ 20MG/HR

INJ HEPARIN @ 1.8 ML/HR

SYP ASCORIL -D 10 ML/PO/TID

SYP CYPROHEPTADINE 5ml/PO/TID

PR/BP/SPO2/ RR CHARTING HRLY

I/O CHARTING

INJ AUGMENTIN 1.2 GM/IV/BD

TAB AZITHROMYCIN 500 MG /RT/OD

NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY

CHEST PHYSIOTHERAPY -6TH HRLY 

INJ OPTINEURON 1 AMP IN 100ML/IV/OD

14/9/21

S
C/o breathlessness

O
Pt is drowsy but arousable
PR - 82/min , regular
RR- 38 cycles/min
SPO2 99% @ 14 LTRS /MIN
BP - 120/70 mmHg- on inotropes
RS - BAE+ COARSE CREPTS + Bilateral IAA, ISA area +
CVS - APEX- 6 TH ICS 1cm lateral to MCL
P/A soft
Stools - didn't pass since 2 days
GRBS - 127 mg/dl
I/0 - 700ml/500ml
A
DCMP with ALCOHOLIC HEPATITIS
CARDIORENAL SYNDROME
METABOLIC ACIDOSIS
ALCOHOL WITHDRAWAL SYNDROME
? PULMONARY EMBOLISM

Yesterday's afternoon reports
His blood urea rose upto 257mg/dl
Serum creatinine 5.7mg/dl
Potassium - 5.5

Albumin - 3.39

Ph - 7.34
Pco2 - 31.2
Hco3 - 16.6
Po2 - 88

With anion gap coming around 26.2
P:
After nephrology opinion we are planning on taking him up for hemodialysis today

Oxygen inhalation
Head end elevation
Fluid restriction < 1.5 ltrs per day
Salt restrictions to < 2 gm/day
RT feeds - 200 ml milk + protein powder/2nd hrly
Plain water 100ml/hrly
INJ NORADRENALINE @ 12 ml/hr ↑/↓ to maintain MAP > 65
INJ DOBUTAMINE@ 10 ml /hr
INJ HEPARIN @ 1.8 ML/HR
SYP ASCORIL -D 10 ML/PO/TID
SYP CYPROHEPTADINE 5ml/PO/TID
PR/BP/SPO2/ RR CHARTING HRLY
I/O CHARTING
INJ AUGMENTIN 1.2 GM/IV/BD Day 2
TAB AZITHROMYCIN 500 MG /RT/OD Day 2
NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY
CHEST PHYSIOTHERAPY -6TH HRLY
INJ OPTINEURON 1 AMP IN 100ML/IV/OD

Blood tinged sputum

2D ECHO

15/9/21

SOAP NOTES

S

Patient is subjectively feeling better

His dyspnea reduced 

O

PR - 100/min , regular

Bp - 140/100mmhg

RR- 28cycles/min

SPO2 99% @ 14 LTRS /MIN

Grbs - 133my/dl

I/o - 1500/1300ml

RS - BAE+ COARSE CREPTS + Bilateral IAA, ISA area +

CVS - APEX- 6 TH ICS 1cm lateral to MCL

P/A soft 

Stools - didn't pass since 2 days

GRBS - 127 mg/dl

I/0 - 700ml/500ml 

A

DCMP with ALCOHOLIC HEPATITIS

CARDIORENAL SYNDROME

METABOLIC ACIDOSIS

ALCOHOL WITHDRAWAL SYNDROME

? PULMONARY EMBOLISM 

P: 

Oxygen inhalation 

Head end elevation

Fluid restriction < 1.5 ltrs per day

Salt restrictions to < 2 gm/day

RT feeds - 200 ml milk + protein powder/2nd hrly

Plain water 100ml/hrly

INJ NORADRENALINE @ 10ml/hr ↑/↓ to maintain MAP > 65

INJ DOBUTAMINE@ 8ml /hr

SYP ASCORIL -D 10 

PR/BP/SPO2/ RR CHARTING HRLY

I/O CHARTING

INJ AUGMENTIN 1.2 GM/IV/BD Day 3

TAB AZITHROMYCIN 500 MG /RT/OD Day 3

NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY

CHEST PHYSIOTHERAPY -6TH HRLY 

INJ OPTINEURON 1 AMP IN 100ML/IV/OD

Will be doing a soap water enema

16/9/21

SOAP NOTES

S

Patient is subjectively feeling much better

His dyspnea and cough has reduced 

O

PR - 100/min , regular

Bp - 140/100mmhg

RR- 25cycles/min

SPO2 99% @ 14 LTRS /MIN

Grbs - 134my/dl

I/o - 1500/1300ml

RS - BAE+ Bilateral Inspiratory crepts in IAA, ISA area +

CVS - APEX- 6 TH ICS 1cm lateral to MCL

P/A soft 

Stools - passed stool yesterday

A

DCMP with ALCOHOLIC HEPATITIS

CARDIORENAL SYNDROME

ALCOHOL WITHDRAWAL SYNDROME

? PULMONARY EMBOLISM 

P: 

Oxygen inhalation 

Head end elevation

Fluid restriction < 1.5 ltrs per day

Salt restrictions to < 2 gm/day

RT feeds - 200 ml milk + protein powder/2nd hrly

Plain water 100ml/hrly

INJ NORADRENALINE @ 4ml/hr ↑/↓ to maintain MAP > 65

INJ DOBUTAMINE@ 4ml /hr

SYP ASCORIL -D 10 

PR/BP/SPO2/ RR CHARTING HRLY

I/O CHARTING

INJ AUGMENTIN 1.2 GM/IV/BD Day 4

TAB AZITHROMYCIN 500 MG /RT/OD Day 4

NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY

CHEST PHYSIOTHERAPY -6TH HRLY 

INJ OPTINEURON 1 AMP IN 100ML/IV/OD

17/9/21

SOAP NOTES

S

His dyspnea and cough has reduced 

His urine has been high coloured since yesterday 

O 

PR - 70/min , regular

Bp - 130/70mmhg

RR- 20cycles/min

Maintaining sats at 90 on Room air 

Grbs - 134mg/dl

I/o  - 1600/1200ml

Stool not yet passed since 3 days

RS - BAE+  Bilateral Inspiratory crepts in IAA, ISA area +

CVS - APEX- 6 TH ICS 1cm lateral to MCL

P/A soft 

His morning ECG

A

DCMP with ALCOHOLIC HEPATITIS

CARDIORENAL SYNDROME

ALCOHOL WITHDRAWAL SYNDROME

? PULMONARY EMBOLISM 

P: 

Oxygen inhalation 

Head end elevation

Fluid restriction < 1.5 ltrs per day

Salt restrictions to < 2 gm/day

RT feeds - 200 ml milk + protein powder/2nd hrly

Plain water 100ml/hrly

Tapered off ionotropes 

SYP ASCORIL -D 10 

PR/BP/SPO2/ RR CHARTING HRLY

I/O CHARTING

INJ AUGMENTIN 1.2 GM/IV/BD Day 5

TAB AZITHROMYCIN 500 MG /RT/OD Day 5

NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY

CHEST PHYSIOTHERAPY -6TH HRLY 

INJ OPTINEURON 1 AMP IN 100ML/IV/OD

18/9/21

SOAP NOTES

40 year old man 

Patient is feeling better. He is  comfortably sitting on his bed. He says his dyspnea has reduced comparatively post admission.

He also happily tells me his dyspnea has reduced. 

However he says he is having disturbed sleep because of cough

O

PR - 89min , regular

RR- 20 cycles/min

SPO2 98% on Room Airt

BP - 100/70 mmHg- on inotropes

RS - BAE+ Reduced breath sounds in B/L IAA,ISA

CVS - APEX- 6 TH ICS 1cm lateral to MCL

P/A soft 

Stools - passed

GRBS - 160mg/dl

I/0 - 1600/1600ml

A

He is maintaining saturations even on Room air

He is accepting feeds orally

HFPEF With pulmonary HTN

Cardiogenic shock resolved

P:

Oxygen inhalation 

Head end elevation

Fluid restriction < 1.5 ltrs per day

Salt restrictions to < 2 gm/day

SYP ASCORIL -D 10 

PR/BP/SPO2/ RR CHARTING HRLY

I/O CHARTING

INJ AUGMENTIN 1.2 GM/IV/BD Day 6

NEB WITH DUOLIN /IN/6 TH HRLY, BUDEORT /IN /12 HRLY

CHEST PHYSIOTHERAPY -6TH HRLY 

INJ OPTINEURON 1 AMP IN 100ML/IV/OD