68 YEAR OLD FEMALE WITH SHORTNESS OF BREATH

65 year old female who used to work as a tailor came to casualty with complaints of shortness of breath since 6 days ,even in sitting position.She also complaints of swelling of limbs since 6 days ,pitting type of edema upto knee since 2 weeks .decreased appetite and increased thirst since 2 days 


HOPI:
patient was apparently asymptomatic 10 years back later she developed SOB ,swelling of whole body for which she was admitted in hospital on 1/7/2012 for which she was diagnosed having dilated cardiomyopathy and severe LV dysfunction a d she was in lasix and later got checked  every yearly on 2D echo which showed following findings 

2014: LV dysfunction, moderate MR/TR,moderate  PAH ,mild AR

2015: decomponsated heart failure / NYHA CLASS III

2016 : admitted with dyspepsia ,vomiting ,cough,SO ,sleepiness and used DYTOR forvtgat and on 2016 June diagnosed to have left sciatica 
2017 : went to hospital with dry cough ,sob ,chest pain and EF=20%

2018: having SOB II ,cough and syncope 

2022: on 25th april went to hospital with loss of appetite ,abdominal discomfort and dysphoria and for which ecg was done and p waves were absent and urea of 52.81 value is observed ,s.creatinine - 3.06 on 25/04/22,rbs: 143 
And patient is on medication for that 
SPRINOLACTONE, AMIADARONE,TORSEMIDE,DIGOXINE, DABIGATRIN 

Past history:
Not a k/c/o DM 
k/c/o HTN since 3 years on medication 

Family history:
Not significant 

Personal history:
Bowel and bladder regular 
No habits / addictions
Menopause obtained


General examination:
Pallor + 
No icterus/cyanosis/clubbing 
Oedema of feet present 


Vitals :
Temp- afebrile
Pr- 86bpm
Rr- 16cpm
BP-110/70 mmhg
Spo2-96% on RA
GRBS- 115mg/dl

Systemic examination:
CVS -s1s2 heard 
CNS - NAD
Respiratory system - dyspnoea present 
BAE+,NVBS HEARD
P/A - soft non tender 

Investigations:
Blood urea- 30 

S.creatinine -1.1

Serum electrolytes:
Na+   140
K+       4.1
Cl-       99

Hemogram :
HB- 12.3
TLC-8500
Plt- 1 78 lkhs
RBC-3.88 million

LFT:
Total bilirubin-2.07
Direct bilirubin-0.58
SGOT               - 41 
SGPT             -   119
ALP               -   183
Total proteins -5.5
Albumin -      3.59


Ecg on 29/4/22:


Ecg on 30/4/22:




2D ECHO ON 29/4/22:


Provisional diagnosis:
Heart failure with reduced ejection fraction secondary to hypertension 
H/O AF with FVR (resolved )

Treatment :
1.TAB DYTOR 10MG PO BD
2  TAB ALDACTONE  50NNG PO OD
3.TAB HYDRALAZINE 12.5MG OD 
4.TAB AMIODARONE 200MG OD
5.TAB DABIGATRAN 110 MG PO OD 
6.TAB PAN 40 MG PO OD
7.SALT AND FLUID RESTRICTED DIET
8.INJ UNFRACTIONATED HEPARIN BD 
5000 IU S/C OR IV 


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