67 YEAR OLD MALE WITH COPD WITH RIGHT HEART FAILURE

CBBLE  UDHC SIMILAR CASE STUDY


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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










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