73 year old female with progressive breathlessness

 DR.NAVYA(INTERN)


DR.CHETANA(INTERN)


DR.ABDUL RAHEEM (INTERN)


DR.ASHFAQ(INTERN)


DR.SRAVYA(INTERN)


DR.GNANADA(INTERN)


DR.CHARAN(PG1)


DR.VAMSI(PG1)


DR.SUSMITHA(PG2)


DR.ADITHYA (PG3)


DR.PRANEETH(PG3) 


DR.PRAVEEN NAIK (ASS.PROF)


DR.RAKESH BISWAS(HOD)




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Here is a case i have seen:

A 73 old female with c/o pedal edema since 1 month .

Dyspnea since 10 days

HOPI-

She presented with a 2 month history of heavy pounding palpitations more often during the day, precipitated by exertion and activity and worsened by leaning forward, relieved with rest .she then started having breathlessness on exertion , which worsened on leaning forward and relieved with rest ( BENDOPNEA). She then started developing pedal edema , first from the feet ,

B/L and gradually ascending to her abdomen and face 

Pedal edema was worse at night initially and resolved in the morning with activity 

Since the last one month, she has been having persistent pedal edema . She also reports nocturia and occasionally feeling dizzy , often on exertion. But also in supine position . She denies having cold hands and profuse sweats ; no h/o insomnia or daytime somnolence 

Past h/o of palpitations - heavy and pounding- very 

occasionally since 30 years 

PAST HISTORY-

Not a k/c/o HTN, DM, TB ,ASTHMA 

No h/o blood transfusion 

No past surgical history 

PERSONAL HISTORY-

single married and widowed

Decreased appetite 

Mixed-diet 

Regular- bowel and bladder movements 

No known allergies

No addictions 

FAMILY HISTORY- PT cannot recall any significant history 

MENSTRUAL HISTORY- 

Age of menarche - 13yrs 

Menstrual cycle -3/30 , 3 pads /day

Age of marriage- 15yrs 

Age at first child - 16 yrs

Attained menopause -20 yrs back 

ON EXAMINATION- 

PT is conscious, well oriented to time ,place and person

Edema of feet - present - B/L grade 3 

Locomotor brachi - present 

No signs of pallor ,icterus, cyanosis, clubbing, lymphadenopathy

VITALS-

Bp-120/80 mmhg, PR-67bpm

Temp- 97.4F , RR- 19cpm 

CVS-

Inspection- 

No visible apical impulse ,

percardial bulge , visible pulsations, dilated veins

palpation-

Apex beat felt at 5th ICS 

no sternal heave 

Mild palpable P2 -present 

Auscultation- soft S1 heard 

RS- 

BAE- present 

Breath sounds- vesicular 

No added sounds

P/A - 

Inspection-

Shape of abdomen - obese 

No visible scars ,sinuses, engorged veins , all quadrants are moving equally with respiration 

Palpation-

Tenderness - not present 

Liver - palpable ( up to 16cm I’m MCL) 

CNS- NAD

INVESTIGATIONS:

DIAGNOSIS: 

HFpEF secondary to CAD with atrial fibrillation with controlled ventricular rate.

TREATMENT:

1.Inj . Lasix 80mg IV BD

2.Tab .Atorvastatin 40mg PO OD 

3. Strict input output charting 

4. Fluid restriction <7.2 L/day

   Salt restriction <3g/day

5. HR and BP monitoring 6th hrly 

6.inj. Optineuron 1 amp in 100 ml Ns Iv od 

7. Tab .pregabalin 75mg hs 

8. Tab pcm 650mg po tid



3.2.2020 SOAP UPDATE.

S

Shortness of breath and chest tightness - decreased comparatively

No other complaints 

O

Pt is conscious, coherent , cooperative 

O/E 

Bp-120/70mmhg

Pr-56bpm 

CVS-S1,S2 +

RS-BAE+

CNS-NAD

I/O-700/1300ml

A

Heart failure with preserved ejection fraction secondary to coronary artery disease with atrial fibrillation with controlled ventricular rate 

1.Inj . Lasix 80mg IV BD

2.Tab .Atorvastatin 40mg PO OD 

3. Strict input output charting 

4. Fluid restriction <7.2 L/day

   Salt restriction <3g/day

5. HR and BP monitoring 6th hrly 

6.inj. Optineuron 1 amp in 100 ml Ns Iv od 

7. Tab .pregabalin 75mg hs 

8. Tab pcm 650mg po tid




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