50 year old female with Chronic Heart Failure


 RACHANA GANGULA 

INTERN 


This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.




A 50 year old female, farmer by occupation presented with the chief complaints of bilateral lower limb swelling on and off since 4 days, complaints of decreased appetite since 15 days, complaints of difficulty in breathing after eating since 15 days, complaints of nausea since 1 week. 


Patient was apparently asymptomatic 15 days back then had developed decreased appetite and had apparently developed difficulty in breathing since 15 days after eating which was associated with burning sensation in the epigastric region and bitter taste in mouth after eating food along with nausea since 1 week. 

No H/O orthopnea, PND, palpitations, SOB on exertion. 



Past history- 

She is a K/C/O heart failure who was admitted 1 year back.

N/K/C/O DM, HTN, TB, Asthma, CAD, CVA 


Personal History- 

Diet- Mixed 

Appetite- normal until 15 days ago 

Bowel and bladder- regular 

Sleep- adequate

Addictions- occasional toddy intake 



Vitals- Temp- afebrile 

PR- 84 bpm 

RR- 18 cpm 

BP- 140/90 mmhg 

GRBS- 102 mg/dl 


General Examination- 

Patient is Conscious, coherent and cooperative 

Well oriented to time, place and person 

Lean built 

Pallor+ 

No Icterus, cyanosis, koilonychia, lymphadenopathy, Edema of lower limbs 


Systemic Examination- 


CVS- 

JVP raised 

S1S2 heard 

Palpable P2 present 

Pansystolic murmur heard 

Parasternal heave felt 


RS- Bilateral Air entry present 

Normal vesicular breath sounds heard 


P/A- no scars / sinus, all quadrants moving equally with respiration

Soft, Non- Tender

Bowel sounds heard 


CNS- NFND, HMF intact

Clinical images- 






LAB INVESTIGATIONS


Blood Urea- 23 mg/dl

Serum Creatinine- 1.0 mg/dl

Serum electrolytes- 

SODIUM -142 mEq/L

POTASSIUM - 3.1 mEq/L

CHLORIDE -103 mEq/L

CALCIUM IONIZED-  1.01 mmolL


HAEMOGLOBIN -9.6 gm/dl 

TOTAL COUNT -5,000 cells/ cumm

PCV -31.4 vol% 

RBC COUNT -3.62 millions/cumm

PLATELET COUNT -2.43 L 


Chest X RAY 




ECG-



DIAGNOSIS 

Right heart failure with hypokalemia with ?GERD 



TREATMENT 

1. TAB. LASIX 20mg PO/BD 

2. TAB METXL- 12.5mg PO/ OD 

3. SYP. POTKLOR 10ml PO/TID

4. TAB. ZOFER PO/OD 

5. TAB. PAN-D 40MG PO/OD 

6. Monitor Vitals 

7. Avoid sleeping immediately after food


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