62M ,ACUTE ON CHRONIC LVF , HFREF (EF-30%) WITH PERMANENT AF WITH FVR , K/C/O. HYPERTENSION
C/o COUGH SINCE YESTERDAY
K/C/O HYPERTENSION 15 YEARS K/C/O ATRIAL FIBRILLATION 10 YEARS K/C/O HEART FAILURE WITH HFrEF K/C/O RECURRENT PEUMONIA
NOT K/C/O CVA, EPILEPSY , THYROID DISORDERS, TB, ASTHMA. PERSONAL HISTORY -
DIET MIXED APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENTS ARE REGULAR SLEEP ADEQUATE
FAMILY HISTORY - NOT SIGNIFICANT GENERAL EXAMINATION -
NO PALLOR
PEDAL OEDEMA IS PRESENT NO ICTERUS
NO CYANOSIS NO CLUBBING NO KOILONYCHIA
TEMPERATURE - 98 F PR - 100 BPM
RR- 32 CPM
BP- 100/60 MMHG SPO2 - 95% AT RA
SYSTEMIC EXAMINATION - CVS -
S1S2 HEARD NO MURMURS , NO THRILLS
RESPIRATORY SYSTEM - DYSPNOEA - PRESENT NO WHEEZE
TRACHEA CENTRAL NVBS + , BAE+
PER ABDOMEN -
OBESE SHAPE
SOFT AND NON TENDER BOWEL SOUNDS HEARD IN RIF CNS - NO FND
GS REFERRAL DONE ON 20/11/24 I/V/O RAW AREA OVER LEFT MEDIAL ASPECT OF THIGH AND KNEE
ADVISED:
DIAGNOSIS: HEALING ULCER OVER THE LEFT THIGH SECONDARY TO CELLULITIS LEFT LOWER LIMB ELEVATION
MEGAHEAL OINTMENT FOR L/A REGULAR DRESSINGS
PLASTIC SURGERY OPINION I/V/O SSG
INVESTIGATIONS ADVISED; X RAY LEFT THIGH AP LATERAL RFT, CRP, WOUND CULTURE C/S
WOUND CULTURE C/S REPORT AWAITED.
SHORTNESS OF BREATH SINCE 10YRS
SWELLING OF BOTH THE LOWER LIMBS SINCE 3 MONTHS.
HOPI :
Patient was apparently asymptomatic day before yesterday then he developed insidious in onset associated with sputum mucoid in consistency , non blood stained, more at night and less during morning.
H/o. Shortness of breath since 10 years , insidious in onset and gradually progressive, which is of grade-lll NYHA , associated with palpitations.
H/O.B/L pitting type pedal edema grade-Ill , more towards evening and less in the evening .
No H/O fever, cough,cold , vomitings , diarrhoea, burning micturition
PAST HISTORY :
K/C/O. Hypertension since 15 years
K/C/O HFREF WITH ATRIAL FIBRILLATION since 10years.
No H/O . DM/TB/ASTHMA/EPILEPSY/THYROID DISORDERS .
TREATMENT HISTORY:
On Tab.GLIMI.M1 since 15 yrs
On Tab.MET.XL 12.5 mg since 10yrs
On Tab. LASIX 20mg since 10yrs
Tab.ECOSPRIN.AV since 10yrs.
PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Bladder and Bowel - Regular
Sleep - adequate
Alcohol - Regular 90ml/day stopped 10 years back
Smokes 1pack/day stopped 10 years back
No drug addictions
FAMILY HISTORY:
No H/O HTN/DM/TB/ASTHMA/EPILEPSY/CAD/THYROID DISORDERS in the family.
PROVISIONAL DIAGNOSIS :
ACUTE IN CHRONIC LVF , HEART FAILURE WITH REDUCED EJECTION FRACTION ( 30%) WI
GENERAL PHYSICAL EXAMINATION:
HEIGHT - 168 cms
WEIGHT - 62 kg
NO PALLOR
NO ICTERUS
NO CYNOSIS
NO CLUBBING
NO LYMPH EDNOPATHY
DAY 1 ON EXAMINATION: 20/11/2024 at 6.45pm
TEMP - 98 f
PULSE - 100/min irregularly irregular.
HR - 132/min irregular heartbeat
APEX PULSE DEFICIT - 32
BP - 100/50 mm of hg
RR - 32 / min
SPO2 - 95% on room air
CVS -S1,S2 PRESENT, NO MURMURS
RS - BAE -PRESENT , B,/L BASAL CREPTS PRESENT
PA - SOFT , NON TENDER
CNS - NFND
PROVISIONAL DIAGNOSIS :
ACUT ON CHRONIC LVF
HEART FAILURE WITH REDUCED EJECTION FRACTION (30%), PERMANENT AF WITH FVR
K/C/O. HYPERTENSION since 15yrs
CHRONIC NON HEALING ULCER OVER RT.THIGH
INVESTIGATIONS ON 20/11/2024
LAB REPORTS:
TREATMENT ON 20/11/2024 at 8am
1.CONTINUOUS CPAP
2.INJ.LASIX 40MG IV.STAT
3.TAB.MET.XL 25MG PO.OD
4.TAB. SACUBITRIL+VALSARTAN.PO.BD
5.TAB. DYTOR PLUS (5/25) PO.OD
6.TAB. DYTOR 5MG.PO.OD
7.TAB.DABIGATRON 110MG.PO.BD
8.INJ.AUGMENTIN 1.2 GM.IV.TID
9.INJ. DOXYCYCLINE 100MG.IV.BD
DAY 2 ON EXAMINATION: 21/11/2024 at 8am
TEMP - 98.2 f
PULSE - 98/min irregularly irregular.
HR - 128/min irregular heartbeat
APEX PULSE DEFICIT - 30
BP - 100/70 mm of hg
RR - 32 / min
SPO2 - 95% on room air
CVS -S1,S2 PRESENT, NO MURMURS
RS - BAE -PRESENT , B,/L BASAL CREPTS PRESENT
PA - SOFT , NON TENDER
CNS - NFND
ECG ON 21/11/2024 6.45am
2D ECHO ON 22/11/2024
TREATMENT ON 20/11/2024 at 8am
1. FLUID RESTRICTION <1.5 LTS/DAY
2.SALT RESTRICTION <1.2GM/DAY
3.CONTINUOUS CPAP
4.INJ.LASIX 40MG IV. BD
5.TAB.MET.XL 25MG PO.OD
6.TAB. SACUBITRIL+VALSARTAN.PO.BD
7.TAB. DYTOR PLUS (5/25) PO.OD
8.TAB. DYTOR 5MG.PO.OD
9.TAB.DABIGATRON 110MG.PO.BD
10.INJ.AUGMENTIN 1.2 GM.IV.TID
11.INJ. DOXYCYCLINE 100MG.IV.BD
12.TAB.ATORVASTATIN 10 MG.PO.OD
FINAL DIAGNOSIS :
ACUT ON CHRONIC LVF
HEART FAILURE WITH REDUCED EJECTION FRACTION (30%), PERMANENT AF WITH FVR
K/C/O. HYPERTENSION since 15yrs
CHRONIC NON HEALING ULCER OVER RT.THIGH.
PATIENT DISCHARGED ON 21/11/2024
Name : IPID : 202451031
UHID : 20241132731 Pay Type : Paying
Age/Gender : 62 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 20/11/2024 06:43 PM
Name of Treating Faculty DR . RAKESH BISWAS [PROF] DR VAMSI KRISHNA (SR)
DR HARI PRIYA (PG3) DR KEERTHI (PG3) DR LOHITH (PG2)
DR SREE TEJA (PG1)
Diagnosis
ACUTE ON CHRONIC LVF
HEART FAILURE WITH REDUCED EF 30% WITH PERMANENT ATRIAL FIBRILLATION WITH FVR
CHRONIC HEALING ULCER OVER LEFT THIGH 3 MONTHS K/C/O HYPERTENSION 15 YRS
Case History and Clinical Findings
C/O COUGH SINCE 1 DAY HOPI-
PATIENT WAS APPARENTLY ASSYMPTOMATIC 1 DAY AGO THRN HE DEVELOPED COUGH , INSIDIOUS ONSET A/W SPUTUM MUCOID SPUTUM , NON BLOOD TINGED MORE AT NIGHT AND LESS DURING MORNING .
H/O BREATHLESS
H/O PEDAL OEDEMA ON AND OFF NO H/O FEVER AND COLD
NO H/O DECREASED URINE OUTPUT AND BURNING MICTURATION NO H/O VOMITING , LOOSE STOOLS AND PAIN ABDOMEN
PAST HISTORY - H/O CELLULITIS 3 MONTHS BACK
UHID : 20241132731 Pay Type : Paying
Age/Gender : 62 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 20/11/2024 06:43 PM
Name of Treating Faculty DR . RAKESH BISWAS [PROF] DR VAMSI KRISHNA (SR)
DR HARI PRIYA (PG3) DR KEERTHI (PG3) DR LOHITH (PG2)
DR SREE TEJA (PG1)
Diagnosis
ACUTE ON CHRONIC LVF
HEART FAILURE WITH REDUCED EF 30% WITH PERMANENT ATRIAL FIBRILLATION WITH FVR
CHRONIC HEALING ULCER OVER LEFT THIGH 3 MONTHS K/C/O HYPERTENSION 15 YRS
Case History and Clinical Findings
C/O COUGH SINCE 1 DAY HOPI-
PATIENT WAS APPARENTLY ASSYMPTOMATIC 1 DAY AGO THRN HE DEVELOPED COUGH , INSIDIOUS ONSET A/W SPUTUM MUCOID SPUTUM , NON BLOOD TINGED MORE AT NIGHT AND LESS DURING MORNING .
H/O BREATHLESS
H/O PEDAL OEDEMA ON AND OFF NO H/O FEVER AND COLD
NO H/O DECREASED URINE OUTPUT AND BURNING MICTURATION NO H/O VOMITING , LOOSE STOOLS AND PAIN ABDOMEN
PAST HISTORY - H/O CELLULITIS 3 MONTHS BACK
K/C/O HYPERTENSION 15 YEARS K/C/O ATRIAL FIBRILLATION 10 YEARS K/C/O HEART FAILURE WITH HFrEF K/C/O RECURRENT PEUMONIA
NOT K/C/O CVA, EPILEPSY , THYROID DISORDERS, TB, ASTHMA. PERSONAL HISTORY -
DIET MIXED APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENTS ARE REGULAR SLEEP ADEQUATE
FAMILY HISTORY - NOT SIGNIFICANT GENERAL EXAMINATION -
NO PALLOR
PEDAL OEDEMA IS PRESENT NO ICTERUS
NO CYANOSIS NO CLUBBING NO KOILONYCHIA
TEMPERATURE - 98 F PR - 100 BPM
RR- 32 CPM
BP- 100/60 MMHG SPO2 - 95% AT RA
SYSTEMIC EXAMINATION - CVS -
S1S2 HEARD NO MURMURS , NO THRILLS
RESPIRATORY SYSTEM - DYSPNOEA - PRESENT NO WHEEZE
TRACHEA CENTRAL NVBS + , BAE+
PER ABDOMEN -
OBESE SHAPE
SOFT AND NON TENDER BOWEL SOUNDS HEARD IN RIF CNS - NO FND
GS REFERRAL DONE ON 20/11/24 I/V/O RAW AREA OVER LEFT MEDIAL ASPECT OF THIGH AND KNEE
ADVISED:
DIAGNOSIS: HEALING ULCER OVER THE LEFT THIGH SECONDARY TO CELLULITIS LEFT LOWER LIMB ELEVATION
MEGAHEAL OINTMENT FOR L/A REGULAR DRESSINGS
PLASTIC SURGERY OPINION I/V/O SSG
INVESTIGATIONS ADVISED; X RAY LEFT THIGH AP LATERAL RFT, CRP, WOUND CULTURE C/S
WOUND CULTURE C/S REPORT AWAITED.
COURSE IN HOSPITAL-
A 62 YR OLD MALE WAS BROUGHT TO CASUAlITY WITH COMPLAINTS OF COUGH WITH SPUTUM SINCE PREVIOUS DAY NIGHT ,A/W BREATHLESSNESS SINCE THEN,PATIENT IS A KNOWN CASE OF HFrEF WITH ATRIAL FIBRILLATION .ON FURTHER EVALUATION PATIENT FOUND TO HAVE ACUTE ON CHRONIC VENTRICULAR FAILURE . TREATMENT WAS STARTED ACCORDINGLY.LATER PATIENT WAS FOUND TO HAVE CHRONIC HELAING ULCER OVER LEFT THIGH FOR WHICH SURGERY OPINION WAS TAKEN AND TREATED ACCORDINGLY. PATIENT IMPROVED CLINICALLY HE IS BEING DISCHARGED IN A HAEMODYNAMICALLY STABLE CONDITION
Investigation
COMPLETE URINE EXAMINATION (CUE) 20-11-2024COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
Anti HCV Antibodies - RAPID 20-11-2024 Non ReactiveHBsAg-RAPID 20-11-2024 Negative HIV 1/2 Rapid Test Non Reactive
A 62 YR OLD MALE WAS BROUGHT TO CASUAlITY WITH COMPLAINTS OF COUGH WITH SPUTUM SINCE PREVIOUS DAY NIGHT ,A/W BREATHLESSNESS SINCE THEN,PATIENT IS A KNOWN CASE OF HFrEF WITH ATRIAL FIBRILLATION .ON FURTHER EVALUATION PATIENT FOUND TO HAVE ACUTE ON CHRONIC VENTRICULAR FAILURE . TREATMENT WAS STARTED ACCORDINGLY.LATER PATIENT WAS FOUND TO HAVE CHRONIC HELAING ULCER OVER LEFT THIGH FOR WHICH SURGERY OPINION WAS TAKEN AND TREATED ACCORDINGLY. PATIENT IMPROVED CLINICALLY HE IS BEING DISCHARGED IN A HAEMODYNAMICALLY STABLE CONDITION
Investigation
COMPLETE URINE EXAMINATION (CUE) 20-11-2024COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
Anti HCV Antibodies - RAPID 20-11-2024 Non ReactiveHBsAg-RAPID 20-11-2024 Negative HIV 1/2 Rapid Test Non Reactive
RFT 20-11-2024UREA 23 mg/dl CREATININE 1.1 mg/dl URIC ACID 3.0 mmol/L CALCIUM 9.8
mg/dlPHOSPHOROUS 2.4 mg/dl SODIUM 142 mmol/L POTASSIUM 3.7 mmol/L.CHLORIDE 106
mmol/L
LIVER FUNCTION TEST (LFT) 20-11-2024Total Bilurubin 1.56 mg/dl Direct Bilurubin 0.45 mg/dlSGOT(AST) 14 IU/LSGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 207 IU/LTOTAL
PROTEINS 5.6 gm/dlALBUMIN 2.97 gm/dlA/G RATIO 1.13
APTT TEST 31
Prothrombin Time 15 secINR 1.11
HAEMOGLOBIN 10.5 gm/dlTOTAL COUNT 7,200 cells/cummNEUTROPHILS 80LYMPHOCYTES 9EOSINOPHILS 1MONOCYTES 10BASOPHILS 00PCV 32.5 vol %PLT- 2.65USG ON 20/11/202427 X 26 MM CYST NOTED IN THE MIDPOLE OF RIGHT KIDNEYFREE FLUID NOTED IN BILATERAL PLEURAL SPACEIMPRESSION -RIGHT SIMPLE RENAL CORTICAL CYSTB/L PLEURAL EFFUSION2D ECHO;TACHYCARDIA AND VPCS DURING STUDY
EF- 30%, IVC SIZE- 2.3CMS DILATED COLLAPSING
SEVERE TR PAH, MOD TO SEVERE MR, MODERATE MR, MILD PR RWMA [+] LAD AKINETIC ; LCX AND RCA HYPOKINESIA NO AS/MS SEVERE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION NO PE/LV CLOT
Treatment Given(Enter only Generic Name) FLUID RESTRICTION LESS THAN 1.2 L / DAY SALT RESTRICTION LESS THAN 1.2 G/DAY INJ. LASIX 40 MG IV STAT
INJ. LASIX 40 MG IV TID TAB. MET XL 25 MG PO/OD
INJ . AUGMENTIN 1.2 GRM IV TID X 3DAYS INJ. DOXYCYCLIN 100 MG IV BD X 3DAYS TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X TAB DYTOR 5 MG PO/OD X-X-4PM
TAB. DABIGATRAN 110 MG PO/BD 1-X-1 TAB ECOSPIRIN AV 75/20PO HS X-X-1
TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO 1/2 BD
mg/dlPHOSPHOROUS 2.4 mg/dl SODIUM 142 mmol/L POTASSIUM 3.7 mmol/L.CHLORIDE 106
mmol/L
LIVER FUNCTION TEST (LFT) 20-11-2024Total Bilurubin 1.56 mg/dl Direct Bilurubin 0.45 mg/dlSGOT(AST) 14 IU/LSGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 207 IU/LTOTAL
PROTEINS 5.6 gm/dlALBUMIN 2.97 gm/dlA/G RATIO 1.13
APTT TEST 31
Prothrombin Time 15 secINR 1.11
HAEMOGLOBIN 10.5 gm/dlTOTAL COUNT 7,200 cells/cummNEUTROPHILS 80LYMPHOCYTES 9EOSINOPHILS 1MONOCYTES 10BASOPHILS 00PCV 32.5 vol %PLT- 2.65USG ON 20/11/202427 X 26 MM CYST NOTED IN THE MIDPOLE OF RIGHT KIDNEYFREE FLUID NOTED IN BILATERAL PLEURAL SPACEIMPRESSION -RIGHT SIMPLE RENAL CORTICAL CYSTB/L PLEURAL EFFUSION2D ECHO;TACHYCARDIA AND VPCS DURING STUDY
EF- 30%, IVC SIZE- 2.3CMS DILATED COLLAPSING
SEVERE TR PAH, MOD TO SEVERE MR, MODERATE MR, MILD PR RWMA [+] LAD AKINETIC ; LCX AND RCA HYPOKINESIA NO AS/MS SEVERE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION NO PE/LV CLOT
Treatment Given(Enter only Generic Name) FLUID RESTRICTION LESS THAN 1.2 L / DAY SALT RESTRICTION LESS THAN 1.2 G/DAY INJ. LASIX 40 MG IV STAT
INJ. LASIX 40 MG IV TID TAB. MET XL 25 MG PO/OD
INJ . AUGMENTIN 1.2 GRM IV TID X 3DAYS INJ. DOXYCYCLIN 100 MG IV BD X 3DAYS TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X TAB DYTOR 5 MG PO/OD X-X-4PM
TAB. DABIGATRAN 110 MG PO/BD 1-X-1 TAB ECOSPIRIN AV 75/20PO HS X-X-1
TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO 1/2 BD
Advice at Discharge
FLUID RESTRICTION LESS THAN 1.2 L / DAY
SALT RESTRICTION LESS THAN 1.2 G/DAY
TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X TO BE CONTINUE TAB DYTOR 5 MG PO/OD X-X-4PM TO BE CONTINUE
TAB. DABIGATRAN 110 MG PO/BD 1-X-1 TO BE CONTINUE TAB ECOSPIRIN AV 75/20 PO HS X-X-1 TO BE CONTINUE TAB. MET XL 25 MG PO/BD 1-X 1/2 TO BE CONTINUE
TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO BD 1/2 -X-1/2 TO BE CONTINUE LEFT LOWER LIMB ELEVATION
MEGAHEAL OINTMENT FOR L/A REGULAR DRESSINGS
Follow Up
REVIEW ON 27/11/24 OR SOS TO GM OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:22/11/24 Ward: ICU
Unit: III
FLUID RESTRICTION LESS THAN 1.2 L / DAY
SALT RESTRICTION LESS THAN 1.2 G/DAY
TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X TO BE CONTINUE TAB DYTOR 5 MG PO/OD X-X-4PM TO BE CONTINUE
TAB. DABIGATRAN 110 MG PO/BD 1-X-1 TO BE CONTINUE TAB ECOSPIRIN AV 75/20 PO HS X-X-1 TO BE CONTINUE TAB. MET XL 25 MG PO/BD 1-X 1/2 TO BE CONTINUE
TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO BD 1/2 -X-1/2 TO BE CONTINUE LEFT LOWER LIMB ELEVATION
MEGAHEAL OINTMENT FOR L/A REGULAR DRESSINGS
Follow Up
REVIEW ON 27/11/24 OR SOS TO GM OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:22/11/24 Ward: ICU
Unit: III
