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A 34 year male patient auto driver by occupation came to the opd with complaints of
Cough with expectoration since 1 week
Chest pain in epigastric region since 1 week
B/L pedal edema since 1 week
Shortness on breath on walking since 1 week
Decreased urine output since 1 week
Generalised weakness since 1 week
Patient was apparently asymptomatic 1 week back then developed cough with expectoration-mucoid in consistency, non blood stained, non foul smelling, developed pedal edema ,Bilateral,progressed from involving ankles to limbs (grade 1 to grade 3),pitting type
PAST HISTORY-
H/o quadriplegia 11 yrs back ?hypokalemia
H/o palpitations ,HR-240bpm,defibrillation done 5years back
H/O TB 4 years back for which he was on ATT for 4 months
Not a known case of DM,HTN,ASTHMA,EPILEPSY,THYROID DISORDERS
PERSONAL HISTORY-
Diet-mixed
Appetite-normal
B &B movements- urine output decreased
Sleep-normal
Addictions- h/o alcohol consumption since past 12 years ,started occasionally then started having alcohol (whiskey ,toddy)regularly since 5 years
AUDIT C score -9/12
Tobacco consumption since 5 years
GENERAL EXAMINATION-
Patient is conscious, coherent, cooperative
Moderately built and moderately nourished
Oriented to time ,place and person
No signs of pallor,icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
VITALS AT ADMISSION:
Afebrile
BP-110/70 mmhg
PR-78bpm
RR-18cpm
SYSTEMIC EXAMINATION-
CVS-
Inspection
Shape of chest- symmetrical
Trachea -central
No scars ,sinuses ,dilated veins
JVP not elevated
Palpation-
All inspection findings confirmed
Trachea -central
Apex beat- left 4th intercoastal space
Auscultation -
S1,S2 heard
No murmurs
RS- normal Vesicular breath sounds heard
No added sounds
CNS-
No facial asymmetry ,all reflexes are normal
GIT
No hepatosplenomegaly,no ascites
Investigations
DIAGNOSIS
Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB
TREATMENT 4/5/22
1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml PO/TID
6. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
7.FLUID AND SALT RESTRICTION
SOAP NOTES AMC DAY 1
S- c/o productive cough
B/l pedal edema
O-
Patient concious,coherent,cooperative
No pallor, icterus ,cyanosis, koilonychia,lymphadenopathy
Vitals -
Temperature-98.6F
BP-110/80mmhg
PR-75bpm
RR-17cpm
Spo2-99%RA
B/L pedal edema -pitting type
Cvs-S1,S2 +,No murmurs
RS-BAE+,NVBS+,No added sounds
CNS-NAD
P/A-Soft,non tender
A-Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB
P-1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml PO/TID
6. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
7.FLUID AND SALT RESTRICTION
SOAP NOTES AMC DAY 2
S- c/o productive cough
O-
Patient concious,coherent,cooperative
No pallor, icterus ,cyanosis, koilonychia,lymphadenopathy
Vitals -
Temperature-98.3F
BP-110/90mmhg
PR-65bpm
RR-17cpm
Spo2-99%RA
Cvs-S1,S2 +,No murmurs
RS-BAE+,NVBS+,No added sounds
CNS-NAD
P/A-Soft,non tender
A-Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB (used ATT)
ESR-06 mm/1st hr
AFB Sputum -negative
P-
1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml PO/TID
6.TAB ACEBROFYLINE &ACETYLCYSTEINE PO/BD
7. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
8.FLUID AND SALT RESTRICTION
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