67 YEAR OLD MALE WITH COPD WITH RIGHT HEART FAILURE
CBBLE UDHC SIMILAR CASE STUDY
67 YEAR OLD MALE WHO IS A FARMER BY OCCUPATION CAME WITH C/O PEDAL EDEMA SINCE 6 MONTHS,
SOB GRADE-2 SINCE 2. MONTHS,
C/O LOW BACK ACHE SINCE 2 MONTHS
HOPI-PT WAS APPARENTLY ASSYMPTOMATIC 6 MONTHS BACK ,THEN HE DEVELOPED INSIDIOUS ONSET OF PEDAL EDEMA (B/L ,PITTING TYPE ). ASSOCIATED WITH
NYHA CLASS-2 SOB SINCE 2 MONTHS WHICH PROGRESSED TO CLASS-3,ASSOCIATED WITH PND SINCE 2 MONTHS
PT IS HAVING LOW BACK ACHEACHE SINCE 2 MONTHS,NOT RELIEVED ON TAKING MEDICATION,
FROM 1 WEEK PT COMPLAINTS OF LOW BACKACHE AGGREVATED,
AND WASN'T ABLE TO SIT OR STAND AND CAME TO HOSPITAL WITH CLASS-4 SOB
PAST H/O-K/C/O COPD AND ON INHALERS SINCE 2 YEARS
NOT A K/C/O DM,HTN,BA,TB
TREATMENT H/O-NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS
PERSONAL H/O-
MARITAL STATUS-MARRIED
OCCUPATION-FARMER
APETITE -NORMAL
BOWEL AND BLADDER MOVEMENTS REGULAR
ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)
FAMILY H/O-NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION-
PT C/C/C
PEDAL EDEMA PRESENT,NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY
VITALS-
TEMP-101 F
BP-120/80 MM HG
PR-110 BPM
RR-28/min
SpO2-88% @ RA, 99,%@ 5 L OF O2
GRBS-133 MG/DL
SYSTEMIC EXAMINATION-
CVS-S1,S2 PRESENT,NO MURMURS
RS-BAE PRESENT,NVBS HEARD
RHONCHI PRESENT
P/A-SOFT,NON TENDER
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
INVESTIGATIONS-
SEROLOGY-
NEGATIVE
TROPONIN-I - NEGATIVE
ECG-
2D ECHO-
USG-
DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
TREATMENT-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
ORTHO REFERAL
SOAP UPDATES
27/3/22
67YEAR/male
S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTEEMITTENT CPAP 4TH HOURLY
SOAP UPDATES
28/3/22
67YEAR/male
S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTEEMITTENT CPAP 4TH HOURLY