88 yrs old Female came to casualty with......
A 88 yrs old Female presented to casualty with
C/o irrelevant talk and altered mental status since 10 days
Shortness of Breath since 3 days
Cough since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 10 days ago and then developed altered mental status on & off and her speech being non cohorent at times and later becoming normal by herself , each episode lasting for 10- 15 mins .
Productive cough 2 days ago
Now dry cough
Shortness of breath since 3 days initially grade III
progressed grade IV in these 3 days.
Later went to outside hospital and 2 D echo was done
2 D echo ( CAD , LAD + territor) , Global Hypokinesia , Severe LV dysfunction
No history of chest pain , palpitations , giddiness.
HISTORY OF PAST ILLNESS:
N/ K/C/O HTN , DM , CVA , Epilepsy , Asthma
PERSONAL HISTORY:
DIET: MIXED
APPETITE: DECREASED
BOWEL AND BLADDER MOVEMENTS: REGULAR
SLEEP: ADEQUATE
ADDICTIONS: NO
ON EXAMINATION :
PATIENT IS CONSCIOUS NON COHERENT AND COOPERATIVE
GENERAL EXAMINATION:
NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDEMA
VITALS:
BP- 90/50 MMHG
PR- 85BPM
RR- 24CPM
SPO2- 88% @RA , 94% on HIGH FLOW O2
GRBS- 126MG/DL
CVS- S1 S2 HEARD. NO MURMURS
RS -Barrel shaped chest , BAE +
Crepts + , Left IAA ,ISA
Bronchial breath sounds ,
Right ISA
PA - soft , nontender
TEMP - AFEBRILE
CNS : Not oriented to T /P/P
NFD
Urinary Electrolytes:
Chloride - 94
Potassium - 30
Sodium - 127
GAIT - NORMAL
GCS- E4V5M6
PROVISIONAL DIAGNOSIS:
HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CAD ?
WITH ANT. WALL MI ?
WITH TRUE HYPONATREMIA
AND WITH RIGHT MILD PLEURAL EFFUSION ?
INVESTIGATIONS:
ON 3/04/2023
ECG :
2D ECHO:
FEVER CHARTING:
Rx :
1. INJ. LASIX 20 mg /IV /BD
2. T . ECOSPRIN GOLD PO/ H/S
75/75/10 mg
3. T. MET XL 25 mg PO /OD
4. INJ. NORAD - DS ( 2 ampoules in 46 ml NS /IV
@ 6 ml / hr )
5. SYP . POTKLOR 15 ml in 1 glass of water PO / TID
6. Fluid restriction
7. O2 supplementation to maintain
Sp O 2 > 94%
ON 4/02/23
Patient is oriented to time and place
VITALS
Bp:- 80/40 mmhg
Pr :- 78 bpm
RR : 22 cycles / min
SpO2: 88% @RA , 94% on HIGH FLOW O2
Rx:
1. T . ECOSPRIN GOLD PO/ H/S
75/75/10 mg
2. T. MET XL 25 mg PO /OD
3. INJ. NORAD - DS ( 2 ampoules in 46 ml NS /IV
@ 6 ml / hr )
4. SYP . POTKLOR 15 ml in 1 glass of water PO / TID
5. Fluid restriction
6. T. SPIRINOLACTONE 50 mg /PO/OD
7. O2 supplementation to maintain
Sp O 2 > 92%
8. Nebulization with SALBUTAMOL 1 respule /stat /
9. Inj. HEPARIN 4000IU/IV/BD
INVESTIGATIONS:
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