78 year old male with farmer by occupation, resident of Annaram came with chief complaints of SOB on exertion, pedal edema and generalised weakness since 20 days
HOPI-
Pt was apparently asymptomatic 3 months back, then developed SOB which gradually progressed from grade 2 to 3.
This was associated with pedal edema and not associated with chest pain or palpitations.
Orthopnea (+)ve, PND (+)
Not h/o facial puffiness, no decreased urine output, no burning micturition
H/o fever on and off since 2 months
Past history-
Pt was diagnosed with dengue 1 month prior
K/c/o DM since 10 years, on T. Zoryl-m2 po/bd
K/C/O serizure disorder, on T. Carbamazepine 200mg po/od
Not k/c/o HTN, CAD, asthma, CVA, TB
No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena
Personal history
Sleep adequate, appetite decreased, bowel movements irregular, bladder regular, occasional alcoholic, non smoker
General examination
O/e- pt is c/c/c
AFEBRILE
BP- 150/80mmgHg
Pr- 81 BPM
Rr-24cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
JVP(-)
Systemic examination
CVS- S1, S2 heard, no murmurs, ?s3, apex in 6th ICS, MCL, no thrills
RS- BAE(+VE), NVBS
P/A- abdomen distended, umbilicus everted, no fluid thrill, soft, BS(+)
Provisional diagnosis-
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
Investigations
ECG
Treatment
Fluid restriction < 1.5L/day
Salt restriction < 2.4g/day
TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)
TAB ZORY - M2 PO/BD
TAB ECOSPRIRIN - AV (70/20) PO/HS
TAB CARBAMAZEPINE 200mg PO/OD
BP-MONITORING 4th HRly
GRBS 6th HRly
8am-2pm-8pm
I/O CHARTING
TEMP CHARTING
Soap notes 22/12/21
78/M
S- no fever spikes, c/o SOB, not passed stools
O-
BP- 120/70mmgHg
Pr- 81 BPM
Rr-24cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
I/o- 500/900
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
P-
Fluid restriction <1.5l/day
Salt restriction <2.5gm/day
Inj LASIX 40mg iv/bd
T. Zoryl-m2 po/bd
T. Carbamazepine 200mg po/od
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
Daily weight monitoring
T. Ecospirin-AV (75/20) po/od
23/12/21
Ward
78/M
S- SOB decreased
O-
BP- 130/70mmgHg
Pr- 93 BPM
Rr-20cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
Soap notes 25/12/21
S- SOB decreased
O-
BP- 140/80mmgHg
Pr- 98 BPM
Rr-18cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
1 unit of blood transfusion was done
Investigations
Endoscopy-
No varices
No bleed in stomach
Few vascular ectasia in the antrum,no active bleed
Soap notes 26/12/21
S- SOB decreased
O-
BP- 130/90mmgHg
Pr- 95 BPM
Rr-20cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
Soap notes 28/12/21
S- SOB decreased
O-
BP- 120/70mmgHg
Pr- 90 BPM
Rr-18cpm
SPO2- 99% @ra
pallor (+)
Pedal edema (+), b/l, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteroneohrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
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