80F with Shortness of breath

LEARNER REPORT

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A 80 yr old lady, mother of three daughters & dailywaged labourer by occupation was brought to casuality with chief complaints of : 

shortness of breath since 10 days 

dry cough since 3 days

Patient was apparently asymptomatic 20 yrs back then she had history of giddiness and headache tried to treat herself with some veggies and herbs for few days to weeks but symptoms didn't subsided for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily. 

6 yrs back she had history of polyuria for which she went to RMP who told her that she had uncontrolled sugars and prescribed Tab.metformin 500 mg once daily.

3 yrs back she had history of pain abdomen and diagnosed with appendicitis and appendicectomy was done

2 yrs back she had shortness of breath initially on exertion and later progressed to even at rest associated with pedal edema and bilateral plueral effusion diagnosed with left lower lobe collapse with acute cardiogenic pulmonary edema then

2D echo showing dilated right and left atria ,concentric LVH ,moderate PAH.

Since then patient had no symptom 

 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest since 3 days associated with dry cough.

General examination: 

Moderate built and moderately nourished.

Pallor present

No cyanosis, clubbing, icterus, LN

pallor present

Vitals : 

Bp 140/70 mmhg

PR 48 bpm irregularly irregular

RR : 20 cpm

Spo2 : 84 on RA, 96 On 4lts O2

CVS : 

Jvp raised

apex beat 2cms lateral to mid clavicular line. 

S1 S2 heard 

No murmurs.

ECG showing bradyarrythmia 

50mm ecg showing p waves 

RS : bilateral air entry present, B/L lower zone crepts present.

CXR showing cardiomegaly with features of pulmonary edema.

P/A : soft and nontender, no organomegaly, bowel sounds heard 

CNS : HMF intact, no focal Neurological deficit.

Investigations : 

CBP : 

Hb 5.5 gm/dl

TLC : 7400

PLT : 2.28 L

microcytic hypochromic with target cells and pencil forms.

LFT : 

TB : 1.05

Db : 0.35

Enzymes - normal

TP : 5.6

Albumin 3.68

RFT : unremarkable

Sr. Mg - 1.7#

Sr. LDH - 218 low

ESR : normal

Retic count : 0.5

Sr. Iron : 49 mg/dl

usg abdomen.

fever chart

Treatment : 

1. Inj. Atropine 0.5ml IV sos

2. Inj. Lasix 40mg IV BD

3. Inj. Clexane 40 mg iv OD

4. Tab. Ecosprin AV 75/10mg HS

Day 2 : 

S- sob decreased, no other complaints

O- Patient BP 120/80mmhg, pR 55 irr/irr, RR 22, spo2 88on RA, 97% on 4L of O2

Day 2

A - sinus bradycardia 2 to ?Drugs ( aten-am) with acute cardiogenic pulmonary edema with Heart failure 2to ? Structural or high output ( Anemia)

P - withholded aten-am, monitoring vitals, bed rest with preload reducing agents. With oral iron supplements.