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70 year old F    C/o Generalized body swelling since 1 month.

Distension of abdomen since 1 month 

SOB on exertion since 1 month

HOPI- Patient was apparently asymptomatic 6 years back, then one day after having her food while walking to wash her hands she suddenly felt giddiness and fell down following which she was taken to near by RMP and referred to higher centre there, she was diagnosed to have  right femur fracture and Denovo HTN . Then she was taken to near by quack and pop cast was applied for left leg following which she had recovery. 

She used  anti hypertensives for 1 month then stopped, now since 1 month sh developed generalized body swelling which is pitting type associated with distension of abdomen and SOB on exertion and loss of appetite.

No h/o chest pain, giddiness, palpiy

PAST HISTORY: N/K/C/O DM,CKD,CVA,CAD

TREATMENT HISTORY: Hypertensive(not on medication)

PERSONAL HISTORY: 

Single, home-maker, 

Lost appetite, non vegetarian, 

Bladder and bowel movements regular,

Micturion normal, no known allergies and no addictions.

FAMILY HISTORY 

No DM,HTNHeart disease,strike,cancersTB asthma 

GENERAL EXAMINATION:

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, malnutrition

Oedwma of feet present- B/L pitting type.

Vitals-. Temp: afebrile 

PR- 88/Min    

RR- 20/Min

BP- 110/70 mmHg

Spo2 -96%at RA

SYSTEMIC EXAMINATION

CVS- No thrills, S1 S2 heard, no murmurs

RS- no dyspnea, wheeze, position of trachea -central, breath sounds-vesicular, crepts present Bilaterally.

P/A - Distended, non tender, no palpable mass, free fluid present- Dull note on percussion.

CNS- Pt is C/C/C, speech normal, no signs of meningeal irritation,

Tone, power and reflexes are normal.

INVESTIGATIONS: 

CBP- 

Hb- 12.     TLC- 9300.    Plt - 2.97

RFT-

U-31.   Cr.1.2.    Na+ 136.   K+ 4.0.   Cl- 100

CUE- 

pus cells-2-3 cells.   RBC- nil, sugar-nil, ALB- nil.

LFT:

TB-1.10.   DB- 0.42.     AST- 37.      ALT-21.    ALP- 180.     TP- 5.8.    Alb- 3.12

SEROLOGY- NEGATIVE.

PROVISIONAL DIAGNOSIS: 

Heart failure with reduced ejection fraction with severe Lv dysfunction (lvef - 25 %) with TR+, MR+, PAH, secondary to hypertensive heart disease , k/c/o hypertension, With ascites with fibroid uterus 

Treatment:

1. Inj LASIX 80 mg iv /od

2. Inj optineuron 1 amp in 100 ml ns /iv/ od

3. Tab. Ramipril 2.5 mg po/od (2 pm)

4. Met - xr 12.5 mg po/od (9am)

5. Salt and fluid restriction

6. Daily weight and abdominal girth monitoring

7. BP/ temp/ pr monitoring

8. Strict i/o charting

Advice at discharge:

(1) TAB.DYTOR 10MG/OD 

        1-----x------x

(2) TAB.RAMIPRIL 2.5 MG/OD

        X-----1-----X

(3) TAB.MET-XL. 12.5 MG/OD

        X-------1------X

(4) TAB HYDRALAZINE 12.5 MG/TID

        1-----1-----1