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


20/2/22

21/2/22

22/2/22




19/2/22

20/2/22


21/2/22



ABG:-
19/2/22


20/2/22


21/2/22













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 

S:Patient is on mechanical  sedation stopped.patient drowsy but arousable
O:E3VTM5
PR - 74 bpm
BP - 160 / 90 mmhg
Spo2 97% on FiO2 21
GRBS - 152gm% at 8:00am
CVS - S1 S2 +
RS - BAE +, coarse creps + in all areas
P/A - soft, no tender

Patient is intubated on 18/02/2022.
1 session of hemodailysis was done on 19/2/22,1cycle of CPR done on 19/2/22

Pt is on SIMV- Vc mode
Fio2-21%
RR-16
VT- 410ml 
PEEP - 5

A- Acute left ventricular failure with severe LV dysfunction  secondary to MI? with pulmonary edema with HFREF? (EF = 35 %) with AKI on CKD with past h/o DM and HTN. Post CPR status

P :-
1. Inj. LASIX infusion @4ml/hr
2)fluid restriction <1.5L/day
3)Salt restriction <4 gm/ day 
4)Neb with duolin and budecort 6th hrly
5)Tab MET XL 50mg RT /OD
6) Tab. AMLONG 5mg/ RT/OD
7)Tab Ecospirin AV(75/20) /RTO/OD/ H/S
8)RT feeds 200ml milk 4hrly
9)Strict i/o monitoring
10) ET & ORAL suctioning every 2nd hrly 
11)Vitals monitoring
 hrly

22/2/22
ICU
Bed 1

S:Patient is on mechanical  ventilator.
 
O:E1VTM4
PR - 98 bpm
BP - 150 / 90 mmhg
Spo2 95%
GRBS - 152gm% at 8:00am
CVS - S1 S2 +
RS - BAE +, 
P/A - soft, no tender

Patient is intubated on 18/02/2022.
3session of hemodailysis was done on 18,19,21,1cycle of CPR done on 19/2/22

Pt is on SIMV- Vc mode
Fio2-21%
RR-18
VT- 320 ml 
PEEP - 6

A- Acute left ventricular failure with severe LV dysfunction  secondary to MI? with pulmonary edema with HFREF? (EF = 35 %) with AKI on CKD with past h/o DM and HTN. Post CPR status

P :-
1. Inj. LASIX infusion @4ml/hr
2)fluid restriction <1.5L/day
3)Salt restriction <4 gm/ day 
4)Neb with duolin and budecort 6th hrly
5)Tab MET XL 50mg RT /OD
6) Tab. AMLONG 5mg/ RT/OD
7)Tab Ecospirin AV(75/20) /RTO/OD/ H/S
8)RT feeds 200ml milk 4hrly
9)Strict i/o monitoring
10) ET & ORAL suctioning every 2nd hrly 
11)Vitals monitoring
 hrly


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