75 yrs old female patient came with complaints of chest pain associated with shortness of breath and pedal edema

 GENERAL MEDICINE CASE








"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

75 yrs old female patient came with complaints of chest pain associated with shortness of breath and pedal edema

Patient was apparently asymptomatic 4 days back and then developed chest pain which is diffuse,non radiating associated with shortness of breath( grade2-3) associated with wheeze and complaints ofpedal edema which is bilateral and pitting type.

No H/o Abdominal distension and no H/o decreased urine output.

Past history:- not a known case of diabetes milletus, hypertension, bronchial asthma, epilepsy.


O/E:


No pallor/Icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

Jvp raised.


Temp-afebrile

PR- 100bpm

RR-24/min

BP-120/90 mmhg

Spo2- 98%at RA

CVS- S1 S2 +,No murmurs

RS- bae+,B/L coarse crepts present.

P/A- soft, non tender 

CNS- No FND.












Investigations:-



USG:-



X ray:-



2d echo




https://youtu.be/fDWJu3Didfw

Provisional diagnosis:-

Heart failure with  secondary to CAD with moderate to severe LV dysfunction with community acquired pneumonia with GB polyps and infected hepatic cyst.

Treatment:-


Inj lasix 40 mg /IV/TID


Inj Augmentin 1.2g/IV/BD


Tab Azithromycin 500mg PO/OD.


Inj Hydrocort 100mg/IV/BD.


Nebulisation with Duolin, budecort with respules 6th hourly.

Inj optineuron 1 amp in 100ml NS/ IV/OD.


Inj pan 40 mg IV/BD







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