Reduced EF secondary to congestive cardiac failure

  This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.


CASE SCENARIO:

This is a case of an 85 year old male presented to OP with Shortness of breath, Vomiting since 2 days and dysphasia.











COMPLAINTS AND DURATION

  • Shortness of breath 
  • Vomiting since 2 days
  • dysphagia 

HISTORY OF PRESENT ILLNESS

Diagnosed with Heart disease 2 years ago. Shortness of breath as of one week ago followed by Dysphagia and vomiting as of 2 days.


HISTORY OF PAST ILLNESS

  • Not a K/C/O HTN, DM, asthma, epilepsy

  • Unhealed ulcerated foot for the past 10 years. Surgery done to graft thigh muscle to the foot but has shown no improvement

TREATMENT HISTORY

  • Thigh muscle graft to feet for non healing ulcer
  • Has been regularly tested for DM and HTN.


PERSONAL HISTORY

  • Appetite - lost

  • Bowels- regular

  • Micturition -normal

  • No known allergies

  • Quit alcohol and Cigarettes 8 years ago on recommendation by physician for non healing ulcer

FAMILY HISTORY


No significant family history


PHYSICAL EXAMINATION

  1. GENERAL

  • Weight - 45kgs

  • Pallor - No

  • Icterus - Yes 

  • Cyanosis - No

  • Clubbing of finger/toes - No

  • Lymphadenopathy - No

  • Oedema - Yes 

  • Malnutrition - yes 

  • Dehydration - No

  • Koilonychia - No 

  • Temperature - afebrile 

  • Pulse rate -143 b/min

  • Respiration rate - 41/min

  • BP 100/70 mmHg 

  • Large surgical scar along right thigh and unhealed ulcer on  right foot






SYSTEMIC EXAMINATION 

  1. CARDIOVASCULAR SYSTEM

  • JVP seen 

  • Apex beat at 6th ICS

  • Cardiac sounds - S1 , S2 positive
  • EF 42%





  1. RESPIRATORY SYSTEM 

  • Dysponea - Yes 

  • Wheeze - Yes

  • Position of trachea - Central 

  • Breath sounds - Vesicular 

  • Adventitious - Rhonchi 


  1. ABDOMEN


  • Soft tender with bowel sounds heard

  • Shape of abdomen - Normal

  1. CENTRAL NERVOUS SYSTEM 

  • Level of consciousness 

  1. Alert

  2. Stuporous 

  • Signs of meningeal irritation

  1. Neck stiffness - no

  2. Kerning’s sign - no

  • Cranial nerves - normal 

  • Motor system - normal

  • Sensory system - normal 

  • Glasgow system - normal 

  • Cerebral signs

  1. Finger nose coordination - Yes

  2. Knee Heel In-coordination - Yes


F.MUSCULO SKELETAL SYSTEM - normal 


G. SKIN - normal

 

H. EXAMINATION OF BREAST - normal


I. EXAMINATION OF ENT - normal


J.EXAMINATION OF TEETH AND ORAL CAVITY - normal


K. EXAMINATION OF HEAD AND NECK  - normal



PROVISIONAL DIAGNOSIS/ DIAGNOSIS


  • Reduced EF secondary to congestive cardiac failure
  • Unhealing ulcer causing pain
  • Failing liver indicated by LFT 

2 D Echo Report 

  • Showed Left Premature Ventricular contraction 
  • Regional Wall Motility Abnormality 
  • Hypokynetics in Right Coronary, left circumflex and Left anterior decending arteries 
  • EF at 42 %
  • Atrial and mitral regurgitation seen 
  • Moderate LV disfunction
  • All chambers dialated, IVC dialated




ECG

  • Depressed QRS complex
  • Shifting of V leads left, indicative of LV hypertrophy
  • Minor S T variations 




Liver function tests

SGOT SGPT and ALP elevated total protein lowered. Could be indicative of failing liver 




Urine exam

Normal


RFT normal 





ABG report

  • Respiratory alkalosis seen which is slightly compensated


Hemogram




Treatment 


  • Diuretics given for Oedema 
  • Carvidelol given as a Ca channel blocker for PVC 
  • Nebuliser and steroids given for SOB 
  • Paracetamol given for fever





Referred to the dept. of surgery for evaluation of ulcer 




I’d like to thank Rakesh Biswas sir , HOD of Medicine and all the Interns and Post graduates who helped me with the case.

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