70 yr female with heart failure

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This is 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.

70y/ F, hailing from Suryapet, home maker, was brought to the hospital with chief complaints of

Generalized body swelling since 1 month
Abdominal distention since 1 month
SOB on exertion since 1 month

Patient was apparently asymptomatic 6 years back, the one day as she was having her food, while walking to wash her hands, she suddenly felt giddy and fell down, following which she was taken to a near by RMP and referred to a higher center, where she was diagnosed with a right femur fracture and denovo hypertension. 

Then she was taken to a near by quack and a pop cast was applied to her leg i/v/o the fractured femur. Her fracture healed well. She was put on anti hypertensive drugs, which she used only for 1 month, after which she stopped talking the medication.

Now, since 1 month she has developed generalised body swelling, pitting type, associated with distention of abdomen, SOB  on exertion and loss of apetite.

No h/o any chest pain, palpitations, giddiness

Patient is not a k/c/o DM, CKD, CVA

Pt is c/c/c

Vitals at admission :-
BP - 100/70 mm Hg 
PR - 88 bpm 
Temp - afebrile 
RR - 18 cpm 
Spo2 - 96% RA

CVS - S1,S2 + , esm +, 
RS - BAE +
P/a - soft, non tender, distended 
CNS - no FND, GCS - 15/15

Diagnosis:-

Heart failure with reduced ejection fraction with severe Lv dysfunction (lvef - 25 %) with TR+, MR+,  PAH, secondary to hypertensive heart disease (chronic pressure overload) , k/c/o hypertension, With ascites with fibroid uterus 

DAY1

VITALS :-

Pt is c/c/c
BP - 140/90 mm Hg
PR - 84 bpm
RR - 18 cpm
Spo2 - 97 RA

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Inj LASIX 40 mg iv /od
2. Inj optineuron 1 amp in 100 ml ns /iv/ od
3. Tab. Ramipril 2.5 mg po/od (2 pm)
4. Met - xl 12.5 mg po/od (9am)
5. Salt and fluid restriction
6. Daily weight and abdominal girth monitoring
7. BP/ temp/ pr monitoring
8. Strict i/o charting

Day 2

VITALS :-

Pt is c/c/c
BP - 140/90 mm Hg
PR - 82 bpm
RR - 16 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Inj LASIX 80 mg - x - 40 mg /iv/bd
2. Inj optineuron 1 amp in 100 ml ns /iv/ od
3. Tab. Ramipril 2.5 mg po/od (2 pm)
4. Met - xl 12.5 mg po/od (9am)
5. Salt and fluid restriction
6. Daily weight and abdominal girth monitoring
7. BP/ temp/ pr monitoring
8. Strict i/o charting

Day 3 

VITALS :-

Pt is c/c/c
BP - 110/80 mm Hg
PR - 84 bpm
RR - 15 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Inj LASIX 80 mg - x - 40 mg /iv/bd
2. Inj optineuron 1 amp in 100 ml ns /iv/ od
3. Tab. Ramipril 2.5 mg po/od (2 pm)
4. Met - xl 12.5 mg po/od (9am)
5. Salt and fluid restriction
6. Daily weight and abdominal girth monitoring
7. BP/ temp/ pr monitoring
8. Strict i/o charting

Day 4 

VITALS :-

Pt is c/c/c
BP - 150/90 mm Hg
PR - 86 bpm
RR - 16 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Inj LASIX 80 mg - x - 40 mg /iv/bd
2. Inj optineuron 1 amp in 100 ml ns /iv/ od
3. Tab. Ramipril 2.5 mg po/od (2 pm)
4. Met - xl 12.5 mg po/od (9am)
5. Salt and fluid restriction
6. Daily weight and abdominal girth monitoring
7. BP/ temp/ pr monitoring
8. Strict i/o charting

Day 5

VITALS :-

Pt is c/c/c
BP - 130/80 mm Hg
PR - 88 bpm
RR - 17 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Tab. RAMIPRIL 2.5 mg/po/od (@2 pm)
2. Tab. MET -XL 25 mg/po/od (@9am)
3. Tab. DYTOR 10 mg/po/od
4. Salt and fluid restriction

Day 6 

VITALS :-

Pt is c/c/c
BP - 140/90 mm Hg
PR - 85 bpm
RR - 16 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Tab. RAMIPRIL 2.5 mg/po/od (@2 pm)
2. Tab. MET -XL 25 mg/po/od (@9am)
3. Tab. DYTOR 10 mg/po/od
4. Salt and fluid restriction

Day 7

VITALS :-

Pt is c/c/c
BP - 140/90 mm Hg
PR - 77 bpm
RR - 16 cpm

CVS - S1, S2 +; ESM +
RS - BAE +
P/A - soft, NT, BS +
CNS - no FND

TREATMENT :- 

1. Tab. RAMIPRIL 2.5 mg/po/od (@2 pm)
2. Tab. MET -XL 25 mg/po/od (@9am)
3. Tab. DYTOR 10 mg/po/od
4. Salt and fluid restriction

Clinical pictures :-

2d echo 
https://youtube.com/shorts/dN5gsrfwoaE?feature=share

EKG
Pedal edema 
Abdominal distention 

Investigations

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