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
P
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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