65yrs old male with acute left ventiricular failure with severe LV dysfunction

 February 28, 2022

FEBRUARY 28, 2022

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER/GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DICUSS OUR INDIVIDUAL PATIENTS PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SLOVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

CHEIF COMPLAINTS:-

C/O shortness of breath since 10-15 days

C/o pedal edema since 20 days

C/o decreased urine output since 10 days

HISTORY OF ILLNESS:-

History of present illness:-

Patient was apparently asymptomatic 20 days ago then he developed bilateral swelling of fat which was progressive along with shortness of breath 15 days back which was sudden in onset no aggravating factors relevied on medication and reduced urine output since 10 days.

History of past illness:-

K/c/o hypertension 

K/c/o diabetes melitus

Exact duration is not known 

PERSONAL HISTORY:-

He is an farmer 65 years old who is alcohol addicted and also smoker and stopped 6 months back

Past h/o a known case of DM,HTN

Treatment h/o- no drug allergies

FAMILY HISTORY:-

no significant family history 

Personal history:-

Appetite- normal

Bowel- regular

Known allergies- no

Addictions- alcohol and smoke

GENERAL EXAMINATIONS:-

Pt is subconscious,non-coherent, and uncooperative 

No pallor/cyanosis/lymphadenopathy

Vitals 

Bp-150/90 mm/hg

Pr-100 bpm

Rr-22 cpm

Spo2- 70%

TREATMENT:-

Inj Lasix 10mg IV/TID

Inj piptaz 2.23mg IV/TID

Inj ciprofloxacin 200mg IV/BD

fluid restriction CVSL/day

Salt restriction 24g/day

Neubilization 

Tab ahlong 5mg RT/OD

Tab metlx 50mg RT/OD

strict I/O monitoring 

Monitor vital

Tab escosprin Av Rt/H/S

Tab nicardia-sr 20mg RT/BD