A 49 year old female resident of Nalgonda came in to casualty with chief complaints of 

c/o fever since 10 days, 

c/o cough since 10 days, 

c/o SOB since 2-3 days,

c/o decreased urine output since yesterday. 


Patient was apparently asymptomatic 10 days back then she developed fever which is of incidious in onset, intermittent and is of low grade fever, subsided on taking medication.

C/O cough since 10 days which is associated with sputum and scanty in amount. C/O shortness of breath which is of grade 4 ( at the time of presentation) and worsening. It has progressed from sob on excertion 5 to 6m months back.

Patient has a h/o pedal edema since 5 to 6 months which is associated facial puffiness.

C/O of decreased urine output since yesterday night.

H/o covid vaccination 8 days back.


PAST HISTORY:

k/c/o HTN since 1 year and is on Tab. TELMA-H (40/12.5 MG) - but is Irregular in taking medications.

-? k/c/o kidney disease 5-6 years back but not on any medications.

Not history of DM, CAD, asthma, TB, epilepsy.

No h/o similar complaints in the past. 


PERSONAL HISTORY:

Patient has mixed diet with normal appetite and adequate sleep. 

She has normal bowel movements and bladder filling. 

No addictions. 


No significant family history or allergic history. 


GENERAL EXAMNATION:

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 179/110 MMHG, 

PR: 112, 

Temp: 98.6 °F, 

RR: 28 CPM, 

SPO2: 82% 

GRBS: 187 MG%


RS: B/L inspiratory crepts all over lung fields. 


CVS: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities. 


INVESTIGATIONS:

1) HEMOGRAM : 

Hb: 8.2

TLC: 13,300

PCV: 22.2

RBC: 2.95

PLT: 3.41


2) LFT:

TB: 1.13

DB: 0.24

SGOT: 34

SGPT: 27

AP: 327

TP: 5.5

A: 3.5

A/G: 1.85


3) RFT:

UREA: 161

CREAT: 10

NA: 130

K: 4

CL: 90


4) SEROLOGY : negative. 


5) ULTRA SOUND :

B/L grade 2 RPD. 

Left simple renal cyst. 


6) 2D-ECHO:

Moderate to severe LV dysfunction ( EF: 35%)

Mixed MR with no MS. 

Mixed TR with mild PAH. 

Mixed AR with sclerotic AV.

Transient LV dilated. 

Diastolic dysfunction. 

No PE/LV clot. 

RWMA present, Lad akainesia, RCA and LCX hypokainesia. 


PROVISIONAL DIAGNOSIS:

HFrEF secondary to? CAD ( EF - 35%) ( LAD - Akinesia). 

-? CKD ( stage 5.) 

-? Cardiogenic pulmonary edema.

Ecg - 30/09/2021




Ecg - 3/10/2021




Rx :
1/10/2021



2/10/2021


3/10/2021

4/10/2021














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