70 FEMALE, HFPEF, PARAXYSMAL AF WITH FVR, K/C/O. HTN


1. COMPLAINTS AND DURATION

c/o pedal edema :: 10 day
c/o shortness of breath :: 10 day

2. HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10 days ago, then he had c/o pedal edema :: 1 day, which was insidious onset, gradually progressive from ankle to below knee, pitting type, aggravated on prolonged standing and sitting.
c/o shortness of breath :: 1 day, insidious onset, progressed from grade I to grade II (NYHA), (SOB on walking)


No c/o cough, palpitations, chest pain, abdominal pain.
No c/o vomiting, loose stools, burning micturition, blood in urine output, facial puffiness.
c/o constipation :: yes, passage of hard stools once in 3–4 days, non-bloody,
straining, no pain while defecation.
c/o tingling sensation in B/L foot and hand :: 4 days

3. HISTORY OF PAST ILLNESS
k/c/o HTN :: 4 months (T. TAB ATENOLOL 25mg p/o)
Not k/c/o T2DM, asthma, CVA, CAD 

Here is the transcribed text from the image:

4. TREATMENT HISTORY
4.1 Diabetes - No / Yes, Details:
4.2 Hypertension - No / Yes, Details: :: 4 months. TAB. ATENOLOL 25mg PO/OD
4.3 CAD - No / Yes, Details:
4.4 Asthma - No / Yes, Details:
4.5 Tuberculosis - No / Yes, Details:
4.6 Antibiotics - No / Yes, Details:
4.7 Hormones - No / Yes, Details:
4.8 Chemo / Radiation - No / Yes, Details:
4.9 Blood Transfusion - No / Yes, Details:
4.10 Surgeries - No / Yes, Details:
4.11 Other - No / Yes, Details:

5. PERSONAL HISTORY
5.1 Single / Married
5.2 Occupation - Farmer
5.3 Appetite - Normal / Lost
5.4 Veg/Non-Veg/Eggitarian : mixed
5.5 Bowels - Regular / Irregular / Constipation

spaced/Hard stools, once in 3–4 days; more bloated these days
5.6 Micturition - Normal / Abnormal, details
5.7 Known Allergies - No / Yes, details
5.8 Habits / Addictions
a) Alcohol - Regular / Occasional / Teetotaler -
b) Tobacco - Snuff / Chewable / smoking - pack years -
c) Drug use - No / Yes, details
d) Betel nut - No / Yes, details
e) Betel Leaf (Pan) - No / Yes

6. FAMILY HISTORY
6.1 Diabetes - No / Yes, details
6.2 Hypertension - No / Yes, details
6.3 Heart disease - No / Yes, details
6.4 Stroke - No / Yes, details
6.5 Cancers - No / Yes, details
6.6 Tuberculosis - No / Yes, details
6.7 Asthma - No / Yes, details
6.8 Any other hereditary disease
6.9 Psychiatrist illness
6.10 Sibling History
6.11 Any other

PROVISIONAL DIAGNOSIS:

1.? HEART FAILURE WITH PRESERVED EJECTION FRACTION

2. PEDAL EDEMA UNDER EVALUATION

3.K/C/O HYPERTENSION SINCE 4 MONTHS

DAY. 1 ON EXAMINATION 17/07/2025

Pt is conscious

coherent
cooperative

BP – 120/80 mmHg
PR – 104 bpm
RR – 16 cpm
SpO₂ – 94 % on room air

CVS – S1, S2 +
RS – B/L NVBS +
Abd – soft, bowel sounds +
CNS – no focal neurological deficit

ECG ON 17/07/2025 7 pm

ECG ON 17/07/20025 10 PM

INVESTIGATIONS ON 17/07/2025

TREATMENT ON 17/07/2025

  1. Tab. Telma 40 PO OD
  2. Tab. Lasix 20 mg PO BD (8 AM – 4 PM)
  3. Salt restricted diet
  4. BP monitoring – 4th hourly
    Add:
  5. T. Ecosprin AV 75/10 mg PO.HS
DAY-2 ON EXAMINATION ON 18/07/2025

A conscious, coherent
Temp – afebrile
PR – 72 bpm

HR- 84 /min

APEX PULSE DEFICIT - 12
RR – 12 cpm
BP – 140/90 mmHg
SpO₂ – 98 % on room air
CVS – S1, S2 +
CNS – NAD
RS – B/L NVBS +
P/A – soft, bowel sounds 

DIAGNOSIS :

1.PARAXYSMAL ATRIAL FIBRILLATION WITH FVR

2.HEART FAILURE WITH PRESERVED EJECTION FRACTION

3.K/C/O HYPERTENSION SINCE 4 MONTHS

ECG ON 18/07/2025  7am

INVESTIGATIONS ON 18/07/2025


TREATMENT ON 18/07/2025 

  1. Inj. AMIODARONE 900 mg in 500 ml NS
    ➤ 33 ml/hr in 6 hrs
    [8:30 am to 2:30 pm]
    ↓ then
    16 ml/hr [2:30 pm to 8:00 am]
    18/7/25 – 19/7/25

  2. Inj. LASIX 20 mg IV BD [8 am – 4 pm]

  3. TAB. TELMA 40 mg PO OD

  4. TAB. ECOSPRIN AV 75/20 mg PO HS
    x – x – 9 pm

  5. SALT RESTRICTED DIET

  6. BP, HR MONITORING – 2nd HRLY

  7. MONITOR VITALS. INFORM RMO

DAY-3 ON EXAMINATION ON 19/07/2025

A conscious, coherent
Temp – afebrile
PR – 62 bpm

HR- 70 /min

APEX PULSE DEFICIT - 8
RR – 12 cpm
BP – 140/90 mmHg
SpO₂ – 98 % on room air
CVS – S1, S2 +
CNS – NAD
RS – B/L NVBS +
P/A – soft, bowel sounds 

DIAGNOSIS :

1.PARAXYSMAL ATRIAL FIBRILLATION WITH FVR

2.HEART FAILURE WITH PRESERVED EJECTION FRACTION

3.K/C/O HYPERTENSION SINCE 4 MONTHS

ECG ON 19/07/2025 at 6.40 AM

2 D ECHO 

TREATMENT ON 19/07/2025

  1. Inj. Lasix 20 mg IV BD (8 am & 8 pm)
  2. Tab. Telma 40 mg PO OD
  3. Tab. Ecosprin-AV 75/20 mg PO HS
    (× – × – 9 pm)
  4. Salt-restricted diet
  5. BP, HR monitoring – 2nd hourly
  6. Monitor vitals, inform SOS
  7. Oint. Thrombophobe T/A BD
DAY-4 ON EXAMINATION ON 20/07/2025

A conscious, coherent
Temp – afebrile
PR – 76 bpm

HR- 84 /min

APEX PULSE DEFICIT - 8
RR – 12 cpm
BP – 120/80 mmHg
SpO₂ – 98 % on room air
CVS – S1, S2 +
CNS – NAD
RS – B/L NVBS +
P/A – soft, bowel sounds 

ECG ON 20/07/2025 

TREATMENT ON 20/07/2025

  1. W/H TAB. LASIX 20mg PO BD [8am – x, 4pm]
  2. TAB. TELMA 40mg PO OD
  3. TAB. ECOSPIRIN-AV 75/20mg PO HS
         x – x – 9pm
  4. SALT RESTRICTED DIET
  5. BP, HR MONITORING – 2nd Hrly
  6. MONITOR VITALS, INFORM SOS
  7. TAB. DYTOR 10mg OD
  8. TAB. MET XL 25mg PO OD


Diagnosis

PAROXYSMALATRIALFIBRILLATIONWITHFASTVENTRICULARRATE HFPEF [ EF 62 % ]

K/C/O HYPERTENSION SINCE 4 MONTHS

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 10 DAYS

C/OSHORTNESSOFBREATHESINCE10DAYS HOPI :

PATIENT WAS APPARENTLY ASYMPYOMATIC 10 DAYS AGO THEN SHE HAS C/O PEDAL EDEMA SINCE 10 DAYS WHICH WAS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE FROMEANKLETOBELOWELBOW,PITTINGTYPE,AGGREVATEDONPROLONGEDSTANDING AND SITTING

C/OSHORTNESSOFBREATHESINCE10DAYS,INSIDIOUSINONSET,PROGRESSEDFROME GRADE 1 (NYHA) TO GRADE 2(NYHA)(80B ON WALKING)

NO C/O COUGH,PALPITATIONS,CHEST PAIN,ABDOMINAL PAIN

NOC/OVOMITING,LOOSESTOOLS,BURNINGMICTURITION,DECREASEDURINE OUTPUT,FACIAL PUFFINESS

C/OCONSTIPATIONSINCE1YR,PASSESHARDSTOOLSONCEIN3-4DAYS,NONBLOOD STAINED, NO PAIN WHILE DEFECATION

C/OTINGLINGSENSATIONINB/LFOOTANDHAMDSSINCE4DAYS PAST HISTORY:

K/C/O HTN SINCE 4 MONTHS(TAB.ATENOLOL 25 MG PO/OD)

N/K/C/O T2DM,ASTHMA,CVA,CAV,TB

PERSONALHISTORY:MARRIED,MIXEDDIET,CONSTIPATION-PASSESHARDSTOOLSONCE IN 3-4 DAYS,NON BLOOD TINGES,NORMAL MICTURITION, NO KNOWN ALLERGIES AND ADDICTIONS

FAMILYHISTORY-NOTSIGNIFICANT GENERAL EXAMINATION:

NOPALLOR,NOICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDALEDEMA, MALNUTRITION

VITALS:-TEMP:AFEBRILE,BP:160/80MMHG,RR:16CPM,PR:104BPM,SPO2:97%ATRA, GRBS-117MG%

SYSTEMIC EXAMINATION CVS-S1S2+,NOMURMURS RS - BAE + , NVBS

PERABDOMEN:SOFT,NONTENDER,NOORGANOMEGALY CNS - NFND,GLASSGOW COMA SCALE E4V5M6

TONERIGHTLEFT

ULNORMALNORMAL LLNORMALNORMAL POWER

RIGHTLEFT UL 5/5 5/5

LL 5/5 5/5 REFLEXES B T S K A

RIGHT +2 +1 +2 +2 +2

LEFT+2+1+2+2+2 COURSE :

PT CAME WITH COMPLAINT OFPEDAL EDEMA SINCE 10 DAYS, SHORTNESS OF BREATH SINCE10DAYS,INCIDENTALFINDINGSINECGLIKEIRREGULARRHYTHM,ABSENTPWAVES WERE NOTED, SERIAL ECG WERE DONE, 2D ECHO WAS DONE , PT WAS DIAGNOSED ASPAROXYSMAL ATRIAL FIBRILLATION WITHFAST VENTRICULAR RATE AND STARTED ON MET-XL WAS GIVEN , PT WAS RESOLVED AND DISCHARGED IN HEMODYNAMICALLYSTABLE STATE

Investigation

LIVER FUNCTION TEST (LFT) 17-07-2025 Total Bilurubin 1.00 mg/dlDirect Bilurubin 0.20 mg/dl SGOT(AST)21IU/LSGPT(ALT)12IU/LALKALINEPHOSPHATASE140IU/LTOTALPROTEINS

7.0 gm/dl ALBUMIN 4.0 gm/dlA/G RATIO 1.41

HEPATITIS-BSURFACEANTIGEN(HBSAg)RAPIDTEST17-07-202506:24:PMNegativeANTI HCV ANTIBODIES (Rapid Test)RAPID 17-07-2025 06:24:PM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 17-07-2025 06:24:PMCOLOUR Pale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

HAEMOGLOBIN13.6gm/dlTOTALCOUNT9600cells/cummNEUTROPHILS45%LYMPHOCYTES 45 %EOSINOPHILS 02%MONOCYTES 08%BASOPHILS 00 %PCV 36.9 vol %M C V 87.6 fl M C H

29.8 pg M C H C 36.6 % RDW-CV 12.6 % RDW-SD 40.9 fl

RBCCOUNT4.2millions/cummPLATELETCOUNT2.570lakhs/cu.mmSMEARRBCNormocytic normochromic WBC With in normal limits PLATELETS Adequate

RFT ProvisionalUREA 22 mg/dl CREATININE 0.8 mg/dlURIC ACID 2.9 mmol/L DHBSCALCIUM 9.8

mg/dl PHOSPHOROUS 2.6 mg/dlreductionSODIUM 135 mmol/L ElectrodePOTASSIUM 2.9

mmol/L.ElectrodeCHLORIDE 106 mmol/L TreatmentGiven(EnteronlyGenericName) TAB.TELMA 40 MG PO/OD

TAB.LASIX20MGPO/BD(8AM-X-4PM) SALT RESTRICTED DIET

BP MONITORING 4TH HOURLY TAB.ECOSPORINAV75/20MGPO/HS(X-X-9PM) INJ.ANIODARONE 900MG IN 500ML NS

Advice at Discharge

TAB DYTOR 10MG MG PO/OD/8AM TO CONTINUE

TAB. MET-XL 50 MG PO/BD(8AM-X-8PM) TO CONTINUE

TABDIBIGATRAN150MGPO/BD(8AM-X-8PMTOCONTINUE TAB.CINOD 10 MG PO/OD 8AM-0-0 TO CONTINUE

SALT RESTRICTED DIET

Follow Up

REVIEW TO GM OPD AFTER 15 DAYS OR SOSy

When to Obtain Urgent Care


INCASEOFANYEMERGENCYIMMEDIATELYCONTACTYOURCONSULTANTDOCTOROR 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 andtheadviceregardingpreventiveaspectsofcare,whenandhowtoobtainurgentcarehavebeen explained to me in my own language


SIGNATURE OF PATIENT /ATTENDER



SIGNATURE OF PG/INTERNEE



SIGNATURE OF ADMINISTRATOR



SIGNATURE OF FACULTY

DischargeDate Date:21/7/25 Ward:AMC

Unit:1

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