47 year female with acute left heart failure
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Here is a case i have seen:
47 year old ayamma came to OPD with complains of abdominal distension since 3 days which is progressing to anasarca.
Dyspnea since 2 days.
HOPI:
Patient was apparently asymptomatic 4 years back later she had an episode of fever with generalised edema for which she admitted in hospital ( Kim's ) and advised for blood transfusion but she Denied and took ?(iron injections). In aug she consulted gynaecologist for abnormal utrine bleeding( 7/28, uses 4 pads/day) and got ultrasound done. H/o viral prodrome 20 days ago.
At present she was having HIFENAC -MR 1 tab/ day for 2 days. Then she had fever,loss of appetite and myalgia.following this she first developed abdominal distension,later paedal edema and facial puffiness. Dyspnea since 2 days.H/o palpitations since 2 days.
No H/o chest pain, frothy urine,nocturia,dysuria,haematuria.
No H/o syncope,cold hands or feets.
Past history-
N/K/C/O- Diabetes, asthma, tuberculosis.
No H/o blood transfusions.
H/o Tubectomy done 23 years ago.
Personal history-
Decreased appetite.
Mixed diet.
Bowel and bladder movements - regular.
No addictions.
No known allergies.
Family history- insignificant.
Menstrual history-
Age of menarche- 13 years.
Age at marriage- 14 years.
Age of first child- 18 years.(p4)
LMP- 5th January 2021.
M.cycle- 5/28, uses 4 pads/ day.
O/E :
Patient is conscious,well orientated to time,place and person.
Pallor - present. Bilateral paedal edema present above the ankle. Platynykia present.
No signs- icterus, clubbing,cyanosis, lymphadenopathy.
HEIGHT:149 cm, WEIGHT: 45 kgs
BMI: 20.3 Kg/m2
Vitals:
Temperature- 98.4 F
Pulse rate- 96 Bpm regular.
Blood pressure- 170/80 mm of Hg in rt.arm
RR- 24cpm
Tongue- appears pale and bluish staining.
CVS:
INSPECTION:
No visible apical impulse.no pricardial bulge, visible pulsations,dilated veins
PALPATION:
Apex beat felt at 5 th ICS.
Thrills- present at apex.
PURCUSSION-
AUSCULTATION-
Loud S1 present;loud P2 present;S3 Accentuating on inspiration- RVS3; Expiration - LVS3
Cervical veinous hum - present.
RESPIRATORY SYSTEM:
INSPECTION-
Trachea appears to be central.
Shoulders are at same level.
No pectus excavatum or pectus carinatum.
No visible pulsations,dilated veins and scars.
Normal vesicular Breath sounds heard.
Bilateral fine Crepitations present in axillary,infra axillary and infrascapular areas.
P/A:
Distended abdomen
Liver palpable
Spleen palpable
Bowel sounds heard
CNS-
NFND, GCS- E4V5M6.
Provisional diagnosis-ACUTE LEFT HEART FAILURE CAUSING RIGHT HEART FAILURE WITH SYSTEMIC ARTERIAL HYPERTENSION.
INVESTIGATIONS:
ECG-
RFT-
Urea- 20 mg/dl
Creatinine-0.8 mg/dl
Uric acid-4.0mg/dl
Calcium-9.6 mg/dl
Phosphorus-2.7
Sodium-144 mEq/L
Potassium-4.1
Chloride-106
HAEMOGRAM-
Hb-4.4 gm/dl
TLC- 5,600 cells/cumm
Platelet count-1.6 lakhs/ cumm
RBC count- 2.97 millions/ cumm
PCV- 16.6%
MCV- 55.9 fl
MCH-14.9 pg
MCH-26.6 %
RDW-CV- 22.3%
SMEAR -
RBC- anisopoikilocytosis with microcytic hypochromic cells pencil formd tear drop cells.
WBC-With in normal limits.
MICROCYTIC HYPOCHROMIC ANAEMIA.
LFT:
Total bilirubin-0.42 mg/dl
Direct bilirubin-0.16 mg/dl
SGOT-17 IU/L
SGOT-15 IU/L
ALP-163IU/L
Total proteins-6.3 mg/dl
Albumin-3.6 mg/dl
A/G Ratio-1.37
BLOOD GROUP - A positive.
2DECHO-Moderate to severe TR- RVSP-65mm of Hg
Moderate PAH
mild AR+/ MR+ ; NO AS/MS
EF- 63%; Minimal PE+
TREATMENT GIVEN
INJ. LASIX 40mg IV/ STAT
TAB. DEPIN( NEPHIDIPINE) 10 mg PO/ STAT
MONITOR VITALS 4 th hourly.
STRICT I/O CHARTING.
ON 2/2/2021
PT. Shifted to female ward
Patient problems - Dyspnea, anasarca and fatigue
S - Significant relief of dyspnea and anasarca.
O - Temperature- 99F
Pulse rate- 78 Bpm regular.
Blood pressure- 130/70 mm of Hg in rt.arm
RR- 22cpm
Tongue- appears pale and bluish staining.
A - Acute Left Heart Failure likely secondary to? acute iron deficiency anemia due to excessive menstrual blood loss (16 pads with full soakage for 7 days in the first week of January )? VIRAL MYOCARDITIS
Investigations-
Sr. Ferritin-
P - Patient refusing blood transfusion. So preferred oral therapy of Ferrous Fumarate. Iron deficit using Ganzoni Formula at 1078mg. Elemental Iron in Ferrous Fumarate is 33% so 300mg of Livogen will be 100mg per day. Will prescribe this therapy for 2 weeks.
TREATMENT GIVEN
1.INJ. LASIX 40mg IV/ STAT
2.Syp. ASCORYL 10 Ml TID
3.TAB. LIVOGRN 150 mgPO/OD ½ HOUR BEFORE FOOD.
4.MONITOR VITALS 4 th hourly.
5.STRICT I/O CHARTING.
3/2/2021.
3/2/2021.