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CHIEF COMPLAINTS:
A 35 year old male patient came to casualty with chief complaints of
1:SOB Since 7-10days
2: Palpitations since 7days
3:Pedal edema since 2days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10days back then he developed sob which was started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest(grade-4). Associated with increase during sleeping position and
relieved during sitting or standing position.
Complaint of cough with expectoration intermittently, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, not foul
smelling, no plugs, no frank blood.
Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides
There is no history of decreased urine output, no history of vomitings,loose stools etc.
History of alcohol binge 1week before the palpitations.
PAST HISTORY:
No history of DM, HTN, CVA,CAD,TB,ASTHAMA
FAMILY HISTORY:
No history of similar complaints in the family. No history of sudden cardiac death in
the family.
PERSONAL HISTORY:
Married
Diet:mixed
Appetite:Normal
Sleep:Adequate
Bowel and bladder movements: regular
Alcoholic since 15yrs occasional but on continuous exposure to smoking as he was working in bar
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative , moderately built and moderately nourished
Pulse- rate 140 beats per min
Rhythm- regular, volume- low volume, equal pulses on both sides and in all peripheral areas, no radio
radial delay, no radio femoral delay.
Blood pressure- 110/70mm Hg
Jugular venous pressure- normal
Respiratory rate - 40 cycles per minute
Spo2 - 98% on room air
Pallor- absent,no icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema- present, bilateral pitting type, extending till ankle
SYSTEMIC EXAMINATION:
A)CARDIOVASCULAR EXAMINATION;
INSPECTION:
No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no diffuse pulsations over precordium, no superficial engorged veins. No scars or sinuses over the skin.
Pulsations seen on the right parasternal region and in the epigastrium.
No prominent pulsations in the aortic, suprasternal area, supraclavicular area, no visible carotid pulsation, no visible pulsations on the back. No kyphosis, scoliosis, drooping of shoulder, winging of scapula.
PALPATION:
Apex beat present in the 6th inter coastal space, left sided, 1cm lateral to the midclavicular line over 2 inter coastal spaces. Parasternal heave present on the right parasternal region, obliterated on pressure.
Palpable second heart sound in the pulmonary area, not associated with palpable thrill in the
pulmonary area.
No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.
AUSCULTATION:
cardiac rate- about 140 beats per minute Regular in rhythm
Mitral area- soft s1 heard, associated with diastolic murmur mid to late low pitched, no presystolic accentutation, more heard on the left lateral position. No radiation of the murmur heard.
Difficult to appreciate when the patient initially came to the hospital but better audible after initial management.
Pulmonary area- loud p2 heard, no murmur heard, no added sounds
Aortic area- s2 with normal split heard, no murmurs or added sounds heard
Tricuspid area- no murmurs or added sounds heard
B)RESPIRATORY EXAMINATION
BAE+
Wheeze present in all areas.
C) EXAMINATION OF ABDOMEN
Soft and non tender
D) CENTRAL NERVOUS SYSTEM EXAMINATION:
No focal neurological deficit
INVESTIGATIONS:
-Complete urine examination
hemogram
Hb : 12.8
total count : 14,100
platelets : 3.93
RBC : 6.04 millions\cumm
-s.creatinine - 1.1mg\dl
- blood urea - 1.0 mg\dl
-PH : 7.43
PCo2 : 26.8 mmHg
PO2 : 76.3 mmHg
HCo3: 17.6 mmol\L
St. HCo3 : 20.4 mmol\L
TCo2 : 35
O2 stat : 94.0
-LFT
total bilirubin : 2.32
direct bilirubin : 0.64
SGPT : 58
SGOT : 34
-ECG
-CXR
-USG ABDOMEN
-2D echo report:Global hypokinesia,moderate LN dysfunctional, all chambers are dilated
PROVISIONAL DIAGNOSIS:
•SVT secondary to multifocal atrial tachycardia •community acquired pnemonia(Right middle lobe consolidation)
•Alcoholic cardiac myopathy(wet beri beri)
TREATMENT:
1)Inj.AUGMENTIN- 1.2gm Iv/BD
2)Tab.CARDARONE 150mg BD
3)Tab.AZITHROMYCIN 500mg po/OD
4)Inj.HYDROCORT 100mg iv/BD
5)Neb-IPRAVENT @10TH hrly
-BUDESERT
6)Inj.LASIX 40mg Iv/TID
7)Inj.THIAMINE 200mg in 50ml/NS/Iv/TID
8)Inj.OPTINEURIN 1amp in 50ml/NS/IV/OD
9)Fluid restriction<1.5L/day
10)Salt restriction<2g/day
11)Strict temperature charting 1hrly
Strict bp charting 2hrly
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