73 years old MALE PATIENT WITH PEDAL EDEMA, SOB WITH PARAXYSMAL AF

73 old male patient came with Complints of
Bilateral pitting type of pedal edema since 1 week
Shortness of breath since 1year
Decrease in appetite since 1year
Palpitations since 1 year
HOPI :
Patient was apparently alright before 1week gradually he devoloped swelling of both the lower limbs , started initially in the foot and then in both the legs it is grade 2 pitting type of edema. No history of trauma, no history of fever, no history of decrease in urine out put. 
SHORTNESS OF BREATH is  gradually progressive and is present even at rest  , PND present, ORTHOPNOEA present. 
Decrease in appetite is associated with flatulence, dyspepsia, and constipation. No history of diarrhoea/vomitings/pain abdomen. 

PAST HISTORY : 
k/c/O Hypertension since 3 years on Tab. Amldipine 
No history of DM/TB/ASTHAMA/EPILEPSY / CAD / SURGERY

PERSONAL HISTORY :
Smoker since 40 years smokes 2packs per day, stopped smoking since 1 year
Chronic Alcoholic since 40 years drinks 90-180ml Ocasionally 
No other addictions
Diet - Mixed
Appetite - Decresed since 1 year
Bowel - constipation
Micturition - Normal
Sleep -impaired

DRUG HISTORY :
Not using any medicines for this and other health issues
No known drug allergy

FAMILY HISTORY :
No history of similar complaints in the family
No history of DM/TB/ASTHAMA /EPILEPSY / CAD
GENERAL EXAMINATION :
No pallor
No icterus
No cynosis
No clubbing
No lymphedenopathy
Bilateral pitting type pedal edema grade 2 present

JVP -Not raised 
Pulse - 68 bpm, irregular, PULSUS ALTERNANCE seen with APEX PULSE DEFICIT of more than 10 present
BP  = 110/70 mm of hg

CVS =S1, S2 present, no murmurs, heart rate is irregular

RESPIRATORY SYSTEM = BAE present, wheeze present in left infra scapulr area

PER ABDOMEN : abdomen is distended, non tender, no organo megaly. 

DIAGNOSIS :
HEART FAILURE WITH PRESERVED EJECTION FRACTION (63%) 
PARAXYSMAL ATRIAL FIBRILLATION
HYPERTENSION since 3years

LAB INVESTIGATIONS :
HEMOGRAM : Hb =13.5 , Tc - 6700, RBC - 4.68
PLT - 2,05,000 
RFT :
Urea - 17 , Creatinine - 1.2
CUC : 
albumin -nil
Sugar - nil
Rbc - nil
Pus cells - 2-3 cells
FBS - 111
PBS - 112

TREATMENT on day 1 in AMC :
Tab. Amldipine 5mg OD
inj. Lasix 20mg BD
Tab. Pan 40 OD
Nebulisation with iprravent 6th hrly, budecort 8th hrly 
ECG ON DAY 1 👇:
CHEST X. RAY ON DAY 1 :
TREATMENT ON DAY 2 in AMC : 
inj. Clexane 40mg subcutaneous BD
inj. Amiodarone 300mg stat followed by 150mg OD
inj. Lasix 20mg BD
Tab. Amldipine 5mg OD
Tab. Met. Xl 12.5mg OD
Tab. Ecosprin 75 mg OD
Cap. Clopitab 75 mg OD
Tab. Atorvas 20 mg OD
Syp. Cremaffin 30 ml HS
Nebulisation with ipravent, budecort 8th hrly

ECG ON DAY 2:
ON EXAMINATION ON DAY 3:

Pulse =70 bpm, regular with APEX PULSE DEFICIT less than 10
BP =110/80mm of hg
CVS =S1, S2 heard, no murmurs, 
RS =BAE prest, NVBS present
PA =distended, non tender 

ECG ON DAY 3 👇:
TREATMENT ON DAY 3 :
INJ. CLEXANE 40mg subcutaneous. OD
INJ. AMIODARONE 150mg iv. OD
Tab. AMLDIPINE 5mg . OD
Tab. MET. XL 12.5mg OD
INJ. LASIX 20mg iv BD
Tab. ECOSPRIN 75mg OD
Tab. CLOPITAB 75mg OD
Tab. ATORVAS 10mg OD
Syp. CREMAFFIN 30mg HS
NEBULISATION with IPRAVENT and BUDECORT 8th hrly

DAY 4 ECG 👇:

ON EXAMINATION :
PULSE =70bpm regular
BP =0130/70 mm of hg
CVS =S1, S2 heard, no murmurs, 
RS =BAE prest, NVBS present
PA =distended, non tender


TREATMENT ON DAY 4 :
INJ. CLEXANE 40mg subcutaneous. OD
INJ. AMIODARONE 150mg iv. OD
Tab. AMLDIPINE 5mg . OD
Tab. MET. XL 12.5mg OD
INJ. LASIX 20mg iv BD
Tab. ECOSPRIN 75mg OD
Tab. CLOPITAB 75mg OD
Tab. ATORVAS 10mg OD
Syp. CREMAFFIN 30mg HS
NEBULISATION with IPRAVENT and BUDECORT 8th hrly

TOOK CARDIOLOGIST OPENION ON DAY 4 :
ADVICED TO :
CONTINUE ANTI HYPERTENSIVES
ADDED :
Tab. CARDARONE 200mg BD
Tab. ACITROM 1mg OD
To stop inj. Clexane 40mg and inj. Amiodarone 150mg.






















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