A 65year old male Heart failure with preserved ejection fraction,moderate PAH,k/c/o COPD,k/c/o Cardiorenal syndrome type 1

 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 patient's 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 the comment box is welcome.

Here is a case i have seen : 

A 65 year old male, farmer by occupation presented with cheif complaints of pedal edema, edema of bilateral hands since 1 month

Decreased appetite since 7 days

C/o cough with sputum on and off

HOPI:

Pt was apparently asymptomatic 1 month ago then he developed decreased urine output, burning micturition, b/l pedal edema pitting type, sob(grade 2) and fever, for which he was admitted and was diagnosed with HFpEF(EF 55%) with moderate PAH type 1, k/c/o COPD with cardiorenal syndrome type 1 with community acquired pneumonia with ckd.  

At that time(29/9/2020)urea:142,creat:7.3,with metabolic acidosis on ABG(HCO3:10), hb:10.9
Pt underwent 4 sessions of dialysis on 1,5,8,10 october 2020 and was put on iv antibiotics (inj augmentin, inj azithro), inj lasix .

On 12/10/2020(at the time of discharge) urea:74mg/dl,creat:1.9mg/dl.
C/o sob subsided,No c/o decreased urine output, burning micturition, chest pain, palpitations, giddiness now
Now b/l pedal edema,edema of b/l hands still present a/w decreased appetite and cough

PAST HISTORY:

Not a k/c/o DM, HTN, CVA, CAD, TB, asthma

TREATMENT HISTORY:

No known drug allergies

PERSONAL HISTORY:

Patient takes mixed diet, appetite normal, sleep adequate, bowel and bladder habits regular, occasionally alcoholic since 20years, smoker since 20yrs 3-4 beedi's/ day 

FAMILY HISTORY: 

No similar complaints in the family 

GENERAL EXAMINATION:

Pt is c/c/c

Vitals:
Temperature-Afebrile on touch 
PR-80bpm
BP-120/80mmhg
RR-18cpm

No Pallor
No Icterus
No Cyanosis
No Clubbing
No koilonychia
No Lymphadenopathy
B/L putting type pedal edema upto thigh  

SYSTEMIC EXAMINATION:

CVS- S1S2 +,No murmurs
RS- BAE+ ,NVBS
P/A- Soft,NT,No organomegaly
CNS-No FND

INVESTIGATIONS:

Hemogram-Hb:9.6
                     TLC:7500
                      Plt: 1.2lakhs
CUE-
Pus cells - 1-2 
Albumin- nil
Epithelial cells- nil
RBC casts- nil

S.Creatinine-1.8

Blood Urea- 58

ECG-


CXR-



USGabdomen-



2D Echo-


TREATMENT:
Salt restriction <2.4g/dl
Fluid restriction <1.5 L/day
Inj.Lasix 20mg BD TID
T.Aldactone 25mg PO BD 
Syp.Potchlor 10ml in 1 glass of water TID PO
Tab.Ecospirin AV 75/20  PO OD H/S
Tab.MVT PO OD 
Bp/pR/SPO2 charting 4th hrly
Strict I/O charting 2nd hrly

DAY 2 :

O/E- Pt is c/c/c 
Afebrile to touch 
PR- 86bpm
Bp-100/60 mmHg
RR-21cpm
Spo2- 99%@RA
Grbs- 106mg/dl
I/O - 400/900
CVS-S1S2+,JVP raised 
RS-BAE+,NVBS
P/A- soft , nontender

INVESTIGATIONS:
Sr.creatine - 3.3

TREATMENT:
Salt restriction <2.4g/dl
Fluid restriction <1.5 L/day
Inj.Lasix 20mg BD TID
T.Aldactone 25mg PO BD 
Syp.Potchlor 10ml in 1 glass of water TID PO
Tab.Ecospirin AV 75/20  PO OD H/S
Tab.MVT PO OD 
Bp/pR/SPO2 charting 4th hrly
Strict I/O charting 2nd hrly
Tab.Telma 20mg po od

DAY3-

O/E- Pt is c/c/c 
Afebrile to touch 
PR- 86bpm
Bp-100/60 mmHg
RR-20cpm
Spo2- 99%@RA
Grbs- 86mg/dl
I/O - 800/1050
CVS-S1S2+,JVP raised 
RS-BAE+,NVBS
P/A- soft , nontender

INVESTIGATIONS:
Serum.electrolytes:Na+ -141
                                  K+ - 3.3
                                  Cl -92 


TREATMENT:
Salt restriction <2.4g/dl
Fluid restriction <1.5 L/day
Inj.Lasix 20mg BD TID
T.Aldactone 50mg PO BD 
Syp.Potchlor 10ml in 1 glass of water TID PO
Tab.Ecospirin AV 75/20 PO OD H/S
Tab.MVT PO OD 
Bp/pR/SPO2 charting 4th hrly
Strict I/O charting 2nd hrly

DAY 4- 

O/E- Pt is c/c/c 
Afebrile to touch 
PR- 71bpm
Bp-120/60 mmHg
RR-20cpm
Spo2- 99%@RA
Grbs- 96mg/dl
I/O - 700/1350
CVS-S1S2+,JVP raised 
RS-BAE+,NVBS
P/A- soft , nontender

INVESTIGATIONS:
Serum.electrolytes: Na+ -140
                                   K+ -3.7
                                   Cl - 91
S.creatinine - 1.6
S.urea - 51


TREATMENT:
Salt restriction <2.4g/dl
Fluid restriction <1.5 L/day
Inj.Lasix 20mg BD TID
T.Aldactone 50mg PO BD 
Syp.Potchlor 10ml in 1 glass of water TID PO
Tab.Ecospirin AV 75/20 PO OD H/S
Tab.MVT PO OD 
Bp/pR/SPO2 charting 4th hrly
Strict I/O charting 2nd hrly

DAY5-

O/E- Pt is c/c/c 
Afebrile to touch 
PR-90bpm
Bp-130/70 mmHg
RR-20cpm
Spo2- 99%@RA
Grbs- 86mg/dl
I/O - 800/1050
CVS-S1S2+
RS-BAE+,NVBS
P/A- soft , nontender

TREATMENT:
Salt restriction <2.4g/dl
Fluid restriction <1.5 L/day
Inj.Lasix 20mg BD TID
T.Aldactone 25mg PO BD 
Syp.Potchlor 10ml in 1 glass of water TID PO
Tab.Ecospirin AV 75/20 PO OD H/S
Tab.MVT PO OD 
Bp/pR/SPO2 charting 4th hrly
Strict I/O charting 2nd hrly



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