A 40 year old male with CARDIORENAL SYNDROME TYPE-2

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Name: Jatoth Jaya

Roll no:47

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION;

Cheif complaints:

 SOB since 4 days (grade 4)

 pedal oedema since 4 days

cough since 4 days

abdominal distention since 4 days 

Decreased urine output since 4 days 

History of present illness;

He was apparently asymptomatic 3yr back.

The patient is a chronic alcoholic and had similar complaints every time he presented to our hospiatl opd partly due to not taking medication and continuing drinking.

Was on intermittent medication of cardivilol.

 On June 14 2019

He presented with pedal oedema(till knee joint)(pitting type),  decreased urine output and SOB with orthopnea to our opd and was admitted. He was diagnosed with dialated cardiomyopathy( DCMP), mitral regurgitation and ejection fraction of 40% .

Treatment given : ramipril 25mg, lasix 40mg and aldactone50mg.

Time in between:

He visited local RMP every time he had the above symptoms and was using carvedilol and spironolactone for relieving his pedal edema.

On April 20 2021

Presented to the opd of our hospital with abdominal distention, SOB, pedal edema since 6 days.

 Further diagnosed with mitral sub mitral aneurysmal posterior annulus. Treatment given:tab cardivas and dytor plus. Patient refused admission.

On September8 2021

He had SOB which got aggravated by walking and lying on the bed.

The pedal edema which was till the knee joint was relieved when he had taken spironolactone the day before.

The cough was with sputum which was white in color and non foul smelling.

Abdominal distention not associated with pain.

Last took alcohol 4days back.

Past History:

Not a known case of Diabetes,Hypertension, Epilepsy, Asthma,Tuberculosis.

Personal History:

Personal history:

Married

Appetite: decreased since 2 days

Non vegetarian

Chronic alcoholic since 23yrs taking 90ml per day.

GENERAL EXAMINATION:

Patient  is conscious, coherent, cooperative 

 Temperature;Afebrile

Clubbing was present

Pedal Edema was present till knee joint.

VITALS:

Bloodpressure:100/70 mmof Hg

Pulse rate:85bpm

Respiratory Rate:35cpm

spO2: 95%

Cardiovascularsystem: S1S2 heard.

Apex beat at 6th intercostal space mid clavicular line.

Respiratory system:

Per abdominal:

Abdomen distended

Shifting dullness present

INVESTIGATION:

Chest x-ray 

ECG:

   

Usg abdomen

      Mild ascites noted

PROVISIONAL DIAGNOSIS:
Heart failure with mid range ejection fraction and pulmonary  arterial hypertension

SOAP NOTES:

 9/9/2021

S: cough has decreased. Stools passed

BP: 100/70;

PR: 88bpm;

RR: 31cpm;

SPO2: 96%

A: DCMP,  Cardio renal syndrome( type II), chronic alcoholic, chronic hepatitis

Treatment 
Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascopil D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly

10/9/2021

40yr old male with dialated cardiomegaly in AMC
S: cough arc with sputum, SOB decreased
O: pr c/c/c
Afebrile
BP:100/60mm hg
PR:88bpm
I/O: 700/900
Weight 63kg
GRBS:120
CVS:s1 s2 heard, apex beat in 6th incostal space mid clavicular line, parasternal heave present.
CNS:NAD
RS: NVBS+
P/A:abdomen distended shifting dullness present
Diagnosis 

DCMP,  

Cardio renal syndrome( type II), 

chronic alcoholic,

 chronic hepatitis

Treatment 

Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascopil D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly

11/9/2021

SOAP notes:
40yr old male with dialated cardiomegaly in AMC
S: cough ass with sputum, sputum decreased  ,pt drowsy but arousable

O: pt c/c/c
Afebrile
BP:90/80mm hg
PR:88bpm
I/O: 500/200
Weight 63kg
GRBS:113 mg/dl
CVS:s1 s2 heard, apex beat in 6th incostal space mid clavicular line, parasternal heave present, JVP raised
CNS:NAD
RS: NVBS+
P/A:abdomen distended shifting dullness present

Differential Diagnosis:

DCMP,  

Cardio renal syndrome( type II), chronic alcoholic, 

chronic hepatitis
Alcohol withdrawal seizures

Treatment:

Fluid restriction <1.5lt /day
Salt restriction<2gm/day
Lasix infusion @2.5ml/hr (20mg/hr)
Syp ascoryl D 15ml PO/TID
Tab. Cardivas 3.125mg PO/BD
Tab. Ecospirin AV(75/10) PO/OD
Sup cyproheptadine 5ml /po/TID
Tab lorazepam 2 mg OD
Tab pregabalin 75 mg OD
T Ben XL OD
Inj lorazepam 1/2 amp /slow IV  if seizure episode
Daily weight monitoring
I/O Charting
BP/RR/temp monitoring 4th hourly