42 yr old male electrician, came to casualty with cheif complaint of

https://varshinireddychada.blogspot.com/2021/07/chief-complaint-year-old-male-patient.html 

42 yr old male electrician, came to casualty with cheif complaint of 
1. SOB grade 4 , progressed from grade 3 since 4-5days 
2.abdominal distension since 4-5 days
3. Bilateral pedal edema upto ankle since 4-5 days .
1yr back diagnosed as TB , used medication for 4days and stopped.

Patient was apparently asymptomatic till July 21 when he was admitted here in Kims ,nkp, with symptoms of SOB , pedal edema ,
 diagnosed as HFrEF with EF= 32% , with COPD, with LEFT ULCER ON FOOT managed conservatively with diuretics, beta blockers , one episode of AF ( paroxysmal) resolved.

Patient continued to consume alcohol 15days after discharge with increased binge drinking since 10days , followed by cough, productive, no diurnal variation , associated with low grade fever and SOB , progressed to grade 4 gradually, associated with orthopnea , with abdominal distension and bilateral pedal edema upto ankle.

Not a k/c/o diabetes/ hypertension/ asthma/epilepsy.
K/c/o alcoholic 180ml whiskey/day since 20yrs .
Gutka consumption since 20yrs.

No similar complaints in the past.
Past history:
2018:
His left foot big toe got hit by iron rod during work, used pain killers but did not subside , foot got swollen the next day, he came to our hospital that day , skin flap from right thigh is grafted to his left foot. He used regular medication for given period. He was fine till 2yrs, then got diagnosed for TB , used medication only for 4days . 

Now before 3months , he got admitted due to jaundice in our hospital, after admission,next day he developed ulcers on left foot ankle, treatment was being given, now again multiple ulcers were developed.


Chronic alcoholic 180ml/day whiskey since 20yrs.

Before 2018 , he was fine with his routine work life.

O/E
Patient is conscious, coherent,co operative.
Afebrile
BP: 90/60mmhg
PR- 112bpm
RESP. RATE: 34CPM
Spo2: 89% room air

CVS:
Parasternal heave +
Apex - visible, diffuse.
S1,S2 heard.

RESP.SYS:
 Dyspnea- grade 4
Wheeze + , bilateral end inspiration.
Position of trachea - central
Adventitious sounds :
Rhonchi + , rales+ , in bilateral ISA . 

PER ABDOMEN:
Soft,Distended.
No any tenderness.
Shifting dullness+
Bowel sounds heard.
CNS : NAD.

INVESTIGATIONS:
 Serum creatinine: 2.1
Blood urea : 75
Serology: negative

2D ECHO:
 Moderate to severe TR+ with PAH : mild MR+ , trivial AR + 
Global akinetic , no AS/MS 
severe LV dysfunction.
No diastolic dysfunction, 
No LV clot. 

PROVISIONAL DIAGNOSIS:
HFrEF with EF=27% ? Beri Beri
With h/o paroxysmal AF (resolved)
With Right sided pleural effusion, secondary to 
     ? Consolidation- CAP
                               - TB
     ? Heart failure
With AKI (?pre renal ) - cardiorenal type 2
With left non healing ulcer over foot , DM - , HTN - .
with h/0 TB ( defaulter ) used medication for 4 days.

TREATMENT:
1. 02 Inhalation @ 4Litres/min.
2.propped up posture.
3.fluid restriction < 1liter/day
4. Salt restriction < 2gm/day
5.Inj. Lasix 40mg / i.v / TID 
    If SBP > 100mmhg.
6.Tab. Ecospirin-Av 75/20mg OD
7. Inj. Thiamine 3amp /i.v / in 100ml NS stat  
8. Neb with IPRAVENT , DUOLIN /stat 
IPRAVENT= 8th hourly
BUDECORT = 12th hourly.
9. Strict I/o monitoring.
10. BIPAP intermittently every 2hrs.
11.Foleys catheterization
12.Inj. Lasix 10amp (vials) 
      20ml.lasix + 30ml NS= 200mg.
      1ml= 200/50= 4mg.
At 2ml/hr ( 8mg/hr).
13. T. Met Xl 25mg /po/stat
14. Inj. HYDROCORTISONE 100mg/i.v /stat
PLEURAL TAP DONE .







BEFORE PLEURAL TAP XRAY
AFTER PLEURAL TAP XRAY  PA VIEW

19/10/2021 INVESTIGATIONS:




BLOOD UREA: 75mg/dl

Plueral fluid analysis

Volume -3ml
Appearance- clear
Colour- pale yellow
Total count- 10cells
DC= 100% L
RBC - nil
Others- nil

20/10/2021

SOAP NOTES DAY 2

ICU BED 2: 

S - 
Sob decreased from grade 4 to grade 2 . 
c/o nocturnal cough and cough agrravated on lying down. 
No fever spikes 
Swelling in left upper limb,thrombophlebitis.

O - 
Patient is conscious,coherent,co operative
pallor+
No icterus,cyanosis,clubbing, lymphadenopathy
BP- 110/70 mmhg on NA -2 ml/hr
PR- 100 bpm , normal volume , irregular
RR - 20/min. 
Spo2-98% at room air
CVS: S1 S2 heard,no murmers
RS: NVBS +, coarse crepts + in bilateral ISA,SSA,MSA
P/A: soft non tender
GRBS: 90mg/dl
I/O: 1400/500mL
CNS: HMF intact.

A: 
HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION ( secondary to consolidation ?CAD ? TB) 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:
1.head end elevation
2.oxygenation to maintain SPO2>90%
3.fluid restriction < 1lt/day
4.salt restriction<2gm/day
5.inj .lasix 10amp(vials) in 30ml NS at 3ml/hr
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Inj . Hydrocortisone 100mg bd
8.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
9.BIPAP - 2nd hrly
10.inj.thiamine 2amp in 50ml NS/iv/TID
11.T. Ecospirin-Av 75/20mg /po/od
12.syp. GRILLINCTUS 10ml/po/TID
13.protein powder 2tbsp in 100ml milk/TID
Plan : pleural fluid analysis
          LDH awaited
          Plueral protein- transudative.

20/10/2021 INVESTIGATIONS:

Pleural LDH- 87
Serum LDH-431
light's criteria=0.2




.        CHEST XRAY AP VIEW

SOAP NOTES DAY 3, 21/10/2021

ICU BED 2

Dr.Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S: 
SOB decreased.
Cough decreased
Orthopnea +
No fever spikes
No fresh complaints.

O:
Patient is c/c/c
Temp: 97.5°f
BP: 110/70mmhg 
      @Nor Ad = 10ml/hr
      @DOBU 4ml/hr 
RR: 21cycles / min
PR: 108Bpm irregular
CNS: HMF intact.
CVS: S1 S2+ , no murmers
RS: NVBS + 
       Fine crepts + in B/L IAA,ISA,MSA.
P/A: soft,non tender
GRBS- 125mg/dl
I/O:1000/1500ml
SPO2: 93% @room temp
Hemogram:
HB- 10.4
TC: 20,800
PLT: 1.5

A:

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION  (TRANSUDATIVE) ?TB 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:

1.head end elevation
2.oxygenation if spo2 <90%
3.fluid restriction < 1lt/day
4.salt restriction<2gm/day
5.inj .lasix 40mg/iv/TID (if SBP >110mmhg)
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
8.BIPAP - 2nd hrly
9.inj.thiamine 2amp in 50ml NS/iv/TID
10.T. Ecospirin-Av 75/20mg /po/HS
11.syp. GRILLINCTUS 10ml/po/TID
12.protein powder 2tbsp in 100ml milk/TID
13.Inj.Nor Ad -2 ampoules in 47ml NS
14.Inj.Dobutamine 1amp in 48ml NS (MAP >60)
15. Inj. Monocef 1gm/IV/BD.
Thrombophobe ointment.

21/10/2021  INVESTIGATIONS:









22/10/21

SOAP NOTES DAY 4, 

ICU BED 2

Dr.Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S: 
SOB decreased.
Cough decreased
Orthopnea +
No fever spikes
No fresh complaints.

O:
Patient is c/c/c
Temp: 97.5°f
BP: 110/60mmhg 
      @Nor Ad = 10ml/hr
      @DOBU 4ml/hr 
RR: 20cycles / min
PR: 100Bpm irregular
CNS: HMF intact.
CVS: S1 S2+ , no murmers
RS: NVBS + 
       Fine crepts + in B/L IAA,ISA,MSA.
P/A: soft,non tender
GRBS- 180mg/dl
I/O:1000/1500ml
SPO2: 96% @room temp


A:

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION  (TRANSUDATIVE) ?TB 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:

1.head end elevation
2.oxygenation if spo2 <90%
3.fluid restriction < 1lt/day
4.salt restriction<2gm/day
5.inj .lasix 40mg/iv/TID (if SBP >110mmhg)
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
8.BIPAP - 2nd hrly
9.inj.thiamine 2amp in 50ml NS/iv/TID
10.T. Ecospirin-Av 75/20mg /po/HS
11.syp. GRILLINCTUS 10ml/po/TID
12.protein powder 2tbsp in 100ml milk/TID
13.Inj.Nor Ad -2 ampoules in 47ml NS
14.Inj.Dobutamine 1amp in 48ml Ns (MAP >60)
15.inj.monocef 1gm/iv/BD

22/10/21 INVESTIGATIONS:




PLEURAL FLUID ADA : 27U/L 

SOAP NOTES DAY 5 , 
23/10/21

ICU BED 2

Dr.Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S: 
SOB decreased.
Cough decreased
Orthopnea +
No fever spikes
No fresh complaints.

O:
Patient is c/c/c
Temp: 98.9°f
BP: 120/80mmhg 
      @Nor Ad = 10ml/hr
      @DOBU 4ml/hr 
RR: 20cycles / min
PR: 96Bpm 
CNS: HMF intact.
CVS: S1 S2+ , no murmers
RS: NVBS + 
       Fine crepts + in B/L IAA,ISA,MSA.
P/A: soft,non tender
GRBS- 180mg/dl
I/O:1850/1800ml
SPO2: 97% @room temp


A:

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION (TRANSUDATIVE) ?TB 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:

1.head end elevation
2.oxygenation if spo2 <90%
3.fluid restriction < 1lt/day
4.salt restriction<2gm/day
5.inj .lasix 40mg/iv/TID (if SBP >110mmhg)
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
8.BIPAP - 2nd hrly
9.inj.thiamine 2amp in 50ml NS/iv/TID
10.T. Ecospirin-Av 75/20mg /po/HS
11.syp. GRILLINCTUS 10ml/po/TID
12.protein powder 2tbsp in 100ml milk/TID
13.Inj.Nor Ad -2 ampoules in 47ml NS
14.Inj.Dobutamine 1amp in 48ml Ns (MAP >60)
15.inj.monocef 1gm/iv/BD
    3rd day

CBNAAT -ve

23/10/21 INVESTIGATIONS:

HEMOGRAM:

HB: 9.0
TC:11,900
PLT:1.10


24/10/21

SOAP NOTES DAY 6

SHIFTED TO AMC

Dr.Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S: 
SOB decreased.
Cough decreased
No fever spikes
No fresh complaints.

O:
Patient is c/c/c
Temp: 98.6°f
BP: 100/70mmhg 
RR: 18cycles / min
PR: 90Bpm 
CNS: HMF intact.
CVS: S1 S2+ , no murmers
RS: NVBS + 
P/A: soft,non tender
GRBS- 128mg/dl
I/O:900/850ml
SPO2: 98% @room temp


A:

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION (TRANSUDATIVE) ?TB 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:

1.head end elevation
2.oxygenation if spo2 <90%
3.fluid restriction < 1lt/day
4.salt restriction<2gm/day
5.inj .lasix 40mg/iv/TID (if SBP >110mmhg)
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
8.BIPAP - 2nd hrly
9.inj.thiamine 2amp in 50ml NS/iv/TID
10.T. Ecospirin-Av 75/20mg /po/HS
11.syp. ASCORIL po/TID
12.protein powder 2tbsp in 100ml milk/TID
13.inj.monocef 1gm/iv/BD DAY 4
    

25/10/21

SOAP NOTES DAY 7

SHIFTED TO AMC

Dr.Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident 
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD

S: 
SOB decreased.
Cough decreased
No fever spikes
No fresh complaints.

O:
Patient is c/c/c
Temp: 98.4°f
BP: 110/80mmhg 
RR: 18cycles / min
PR: 102Bpm 
CNS: HMF intact.
CVS: S1 S2+ , no murmers
RS: NVBS + ,no crepts
P/A: soft,non tender
GRBS- 102mg/dl
I/O:1050/1000ml
SPO2: 98% @room temp


A:

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)
- with RT. PLEURAL EFFUSION (TRANSUDATIVE) ?TB 
- with CARDIORENAL TYPE 2 syndrome
- left non healing ulcer on left foot
- h/o ? TB (DEFAULTER) used medication for 4 days only
- with COPD with CLD

P:

1.head end elevation
2.oxygenation if spo2 <90%
3.fluid restriction < 1lt/day
4.salt restriction<2.4gm/day
5.tab .lasix 40mg/po/BD 
6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min
7.Neb- with IPATROPIUM - 8th hrly
                    BUDECORT - 12th hourly
8.BIPAP - 2nd hrly
9.inj.thiamine 2amp in 50ml NS/iv/TID
10.T. Ecospirin-Av 75/20mg /po/HS
11.syp. ASCORIL po/TID
12.protein powder 2tbsp in 100ml milk/TID
13.inj.monocef 1gm/iv/BD DAY 5

PLAN FOR DISCHARGE.
    
















 


 






























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