70yr old male with Heart failure with mid range EF with Dilated cardiomyopathy

70 yr old male who is a farmer  from Amanabolu .Complaints of shortness of breath since 3 months intially Grade 2 progressed to Grade 3 associated with orthopnea +,giddiness+ immediately on standing since 10 days ,pedal edema + since 2 months
Complaints of pain in the right shoulder elbow since One year( hit with stick by son )
No h/o chest pain,palpitations, decreased urine output 
Patient was apparently asymptomatic 3 months back then developed shortness of breath which was initially grade 2 and progressed to grade 3 a/w orthopnea and patient started developing pedal oedema since 2 months, grade 3 which was gradually progressing and relieved on  medications 
Past history:
Not a k/c/o DM,HTN,TB,Asthma, Epilepsy. 
K/c/o heart failure. 
Personal history:
Diet intake normal,appetite normal 
Bowel and bladder movements regular 
No known allergies
Occasionally drinks toddy.
General examination:
Patient is conscious ,coherent, cooperative,.
Temp:febrile
Bp:90/70 mmhg
PR: 74bpm
RR: 16 cycles per min
Sp02 :97%
CVS:
S1,S2 heard
RS: BLAE +
P/A :soft,non tender
CNS : NAD
Provisional Diagnosis: Heart failure with mid range ejection fraction with dilated cardiomyopathy with rotatory cuff tendiniti sencondary OA Right Elbow ,OA Right knee with synovitis.
On the day of admission 
treatment :1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
DAY-1 :
                   1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
                   7.Tab zincovit po/OD
                   
DAY-2 :      1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
                   7.Tab zincovit po/OD
                   8.Tab.clopidogrel 75 mg po/OD
                   9.Tab.Sorbitrate 5 mg po/OD
patient c/o pain over right shooulder on right elbow. H/o trauma 1 yr ago over right arm
O/L/E-
Right sholuder-Diffused tenderness,Rom-painful and Restricted 
Right Elbow--Diffused tenderness,Rom-painful and Restricted
Investigation -X ray Rt shoulder Ap ,lateral-sclerosis at greater tuberosity
x- ray Rt elbow AP , Lateral -osteophyte formation both over Radius Ulna articular margins
2D ECHO
USG ABDOMEN

                


Popular posts from this blog

46 yr old male with HFrEF with type 4 cardi renal symdrom with DCMP with ischemic Hepatits

Image
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. Team: Interns- M Supriya Mohitha K Sowmya Sanjay Amrutha Dr.Druga Krishna PGY1 Dr.Ajith Kumar PGY2 Dr.Laxma Reddy PGY3 Dr.Manasa PGY3 Dr.Vijaya Lakshmi (Ast.Prof.) 46 years old old male patient came with  c/o abdominal distension since 20 days   c/o shortness of breath since 20 days and c/o  pedal edema since 20  days Patient was apparently asymptomatic 6 years back then had  throne pricking on the left foot followed which he developed swelling ...
Read more

75 YRS OLD FEMALE WITH CVA

Image
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. Team: Interns- M Supriya Mohitha K Sowmya Sanjay Amrutha Dr.Druga Krishna PGY1 Dr.Ajith Kumar PGY2 Dr.Laxma Reddy PGY3 Dr.Manasa PGY3 Dr.Vijaya Lakshmi (Ast.Prof.) C / o altered sensorium  Unable to speak Unable to move her upper and lower Limbs since  6 o'clock in the evening yesterday Patient had history of toddy intake in the afternoon yesterday after which she unable to move her right upper limb and lower Limbs ⁶6ťshe unable to speak ok or response two daughters...
Read more

50 yrs old male k/c/o HbsAg +ve with cirrhosis

Image
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. Team: Interns- M Supriya Mohitha K Sowmya Sanjay Amrutha Dr.Druga Krishna PGY1 Dr.Ajith Kumar PGY2 Dr.Laxma Reddy PGY3 Dr.Manasa PGY3 Dr.Vijaya Lakshmi (Ast.Prof.) A 50 year old male came with c/o distention of abdomen since 7 months,B/L pedal edema since 7 months,  pt was apparently asymptomatic 7 months back then he developed  low grade fever with yellowish discolouration of eyes followed by pedal edema  which is gradually progressive and pitting type -no aggr...
Read more