65yrs old male patient came to casually with c/o shortness of breath and pedal edema
A 65 yr old male was brought to casualty with c/o SOB since 5 days, pedal edema since 20 days.
Patient was apparently asymptomatic 5 years back - was diagnosed with hypertension and diabetes when he visited a local hospital for fever.
6 to 7 months back - He started to experience Dyspnea, which was sudden onset, progressive.
He also complained of orthopnea.
He was diagnosed with CAD and he underwent at CAG on 19/10/2021 which reveled single vessel disease - LAD territory. The patient also underwent renal angiogram and and was found to have bilateral renal artery stenosis with 90% of Left renal artery to be stenosed and was advised renal artery stenting. He also had OM3 70% stenosis, proximal LAD 50 %, right renal artery 50%, left renal artery 90% stenosis.
PTCA with OM2 and PTRA to left renal artery was done on 12/11/21.
Since 15 days he has SOB. patient presented with SOB grade 3-4 and pedal edema since 20 days. Abdominal distension present.
Patient was chronic alcoholic and smoker stopped 6 months back.
Vitals :
PT - conscious, non coperative
Pedal edema +
Temp afebrile
PR - 100 bpm
BP - 150 / 90 mmhg
Spo2 g 70 %
GRBS - 280 gm%
CVS - S1 S2 +
RS - BAE +, coarse creps + in all areas
P/A - soft, no tender
CNS - patient isndrowsy, NAD
Patient is intubated on 18/02/2022.
2 hrs of hemodailysis was done on 18/02 /2022 - UF IS 2000ml
Pt is on ACMV - Vc mode
Fio2-100%
RR-22
VT- 340 ml
PEEP - 6
Investigations:-
ECG:-
X-ray:-
18/2/22
Diagnosis - acute left ventricular failure with with severe LV dysfunction secondary to MI? with pulmonary edema with HFREF? (EF = 35 %) with AKI on CKD with pst h/o DM and HTN.
Rx:
1. Inj. LASIX 40mg IV /TID
2. Inj OPTINEURON 1amp in 100ml NS IV /OD
3. INJ HYDROCORT 100mg IV /BD
4. Neb with duolin and budecort 6th hrly
5. RT feeds 200ml milk 4th hrly
6. Fluid restriction < 1.2 l/day
7. Salt restriction < 4gm /day
8. Strict i/o monitoring
9. Vitals monitoring hrly
10. Tab MET XL 50mg RT /OD.
20/2/22
Soap notes
ICU Bed 1
S:Patient is on mechanical ventilator. Unconscious.
O:Patent unconscious
Pedal edema +
Temp afebrile
PR - 100 bpm
BP - 150 / 90 mmhg
Spo2 g 70 %
GRBS - 126 gm%
CVS - S1 S2 +
RS - BAE +, coarse creps + in all areas
P/A - soft, no tender
CNS - patient isndrowsy, NAD
Patient is intubated on 18/02/2022.
1 session of hemodailysis was done yesterday
Pt is on SIMV- Vc mode
Fio2-40%
RR-18
VT- 340 ml
PEEP - 7
Diagnosis - acute left ventricular failure with with severe LV dysfunction secondary to MI? with pulmonary edema with HFREF? (EF = 35 %) with AKI on CKD with pst h/o DM and HTN.
Rx:
1. Inj. LASIX 40mg IV /TID
2. Inj OPTINEURON 1amp in 100ml NS IV /OD
3. INJ HYDROCORT 100mg IV /BD
4. Neb with duolin and budecort 6th hrly
5. RT feeds 200ml milk 4th hrly
6. Fluid restriction < 1.2 l/day
7. Salt restriction < 4gm /day
8. Strict i/o monitoring
9. Vitals monitoring hrly
10. Tab MET XL 50mg RT /ODI
21/2/22
ICU
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