A 70 YEAR OLD FEMALE PREVIOULSY LABOURER BY OCCUPATION CAME WITH COMPLAINTS OF SOB AT REST SINCE 10DAYS
A 70 year old female previoulsy labourer by occupation came with complaints of SOB at rest since 10days
HOPI: patient was apparently asymptomatic 5 years back then she had chest pain radiatiing to left hand diagnosed as MI here and referred to higher centre- yashoda where PTCA was done
She was fine for the next 4 years but stopped doing the labour work as adviced by the doctor and would look after a shop and few household works.
Then she had second attack in october 2021 went to osmania planned for PTCA but not done as she developed dyselectrolemia and her creatine was also raised to 3. They suggested the correction of electrolytes and then plan PTCA but the patient attenders were not willing and left against medical advice.
After the second attack the patient even stopped looking after the shop
She was on CARVEDIOL, ECOSPORINE, TORSEMIDE AND SPIRONOLACTONE , HYDROCHLORTHIAZIDE since then.
She has been having on & off episodes of SOB for which she had medical advice here once in november , december , january and now in march she came with similar complaints SOB at rest (grade 4) associated with orthopnea & PND not associated with chest pain, palpitations.
Loss of appetite present
Neck pain present
No h/o fever,cough, cold
Not a K/C/O DM, HTN, ASTHMA,EPILEPSY
GENERAL EXAMINATION
patient is c/c/c
Pallor present,
no icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS:
Temperature: 98.6
Bp:110/80 mmhg
PR:72
RR: 31
Spo2: 99 on RA
CVS : S1 S2 heard
RS: BAE
CNS: NAD
P/A:soft, non tender
Diagnosis: AKI ON CKD HFrEF with EF 45%
CAD -TVD , severe LV dysfunction s/p PTCA TO LAD
TREATMENT :
1. FLUID RESTRICTION<1lit/day
2.SALT RESTRICTED DIET <2.4gm/day
3.O2 SUPLLIMENTATION @ 2-4 lit/day
4.INJ.LASIX 40mg/IV if SBP > 120mmhg
5.HEAD END ELEVATION-40degrees
6.T.ALDACTOME-25mg/PO/OD 8am
7.T.NODOSIS 500mg/PO/OD
8.T.LAVOGEN/PO/OD
9.T.ECOSPORIN 150mg/PO/OD
10.T.ATORXAS 20mg /PO/OD
11.T.CLOPITOGREL 150mg/PO/OD
12.PROTEIN X POWDER
13.STRICT I/O CHARTING
14.NEB WITH DUOLIN 12th hrly
