50y old male with Heart Failure
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A 50 year old male, driver by occupation came to the casuality with the complaints of
- Shortness of breath since 3 days
- Chest pain since 3 days
History of presenting illness:
The patient was apparently asymptomatic 4 years back when he developed left hemiplegia.
He was then diagnosed with both Hypertension and Diabetes for which he is on regular medication.
He stopped working then but could do his regular work without any support.
On 19-June, he came with complaints of shortness of breath, chestpain and palpitations since 4 days.
SOB was grade 2-3 associated with orthopnea and PND.
He had pedal edema on and off since 1 year increased in evenings.
He had no history of fever.
He had complaints of nocturnal micturition.
ECG when presented :
Chest xray :
All the blood investigations were found to be normal.
USG report showed grade 1 fatty liver.
Provisional diagnosis :
Heart failure with preserved ejection fraction
Treatment :
Day 1
Inj Lasix
Inj Augmentine
Day 2
Inj lasix
Inj pan
Inj Augmentine
Inj Azithromycin
Inj Ecosprin
Day 3
Added
Inj Hydrocort
Day 4
Continuing same medication.
DISCHARGE SUNMARY :
Discharge Type: Relieved
Admission Date: 19/06/2021 01:20 PM
Discharge Date
Date : 23-JUNE-2021
Ward : ICU
Unit : 6
Name of Treating Faculty
DR. ARJUN KUMAR (ASS. PROF)
DR. AJITH KUMAR (PGY2)
DR. DURGA KRISHNA (PGY1)
DR. KEERTHI (INTERN)
DR. SREEJA (INTERN)
DR. SRIYA (INTERN)
DR A.VAISHNAVI (INTERN)
DR. SHREYA (INTERN)
Diagnosis
HEART FAILURE WITH PRESERVED EJECTION FRACTION
Case History and Clinical Findings
A 50 year old male, driver by occupation came to the casuality with the complaints ofShortness of
breath since 3 daysChest pain since 3 daysHistory of presenting illness:The patient was apparently
asymptomatic 4 years back when he developed left hemiplegia.He was then diagnosed with both
Hypertension and Diabetes for which he is on regular medication.He stopped working then but could
do his regular work without any support.On 19-June, he came with complaints of shortness of breath,
chestpain and palpitations since 4 days.SOB was grade 2-3 associated with orthopnea and PND.He
had pedal edema on and off since 1 year increased in evenings.He had no history of fever.
He had complaints of nocturnal micturition
Admission Date: 19/06/2021 01:20 PM
Discharge Date
Date : 23-JUNE-2021
Ward : ICU
Unit : 6
Name of Treating Faculty
DR. ARJUN KUMAR (ASS. PROF)
DR. AJITH KUMAR (PGY2)
DR. DURGA KRISHNA (PGY1)
DR. KEERTHI (INTERN)
DR. SREEJA (INTERN)
DR. SRIYA (INTERN)
DR A.VAISHNAVI (INTERN)
DR. SHREYA (INTERN)
Diagnosis
HEART FAILURE WITH PRESERVED EJECTION FRACTION
Case History and Clinical Findings
A 50 year old male, driver by occupation came to the casuality with the complaints ofShortness of
breath since 3 daysChest pain since 3 daysHistory of presenting illness:The patient was apparently
asymptomatic 4 years back when he developed left hemiplegia.He was then diagnosed with both
Hypertension and Diabetes for which he is on regular medication.He stopped working then but could
do his regular work without any support.On 19-June, he came with complaints of shortness of breath,
chestpain and palpitations since 4 days.SOB was grade 2-3 associated with orthopnea and PND.He
had pedal edema on and off since 1 year increased in evenings.He had no history of fever.
He had complaints of nocturnal micturition
Investigations
Investigation
COV RTPCR, ABG, CUE, BLOOD UREA, SERUM ELECTROLYTES.
Name Value Range Name Value Range
SARS-COV-2
Qualitative PCR 19-
06-2021 11:38:AM
Negative ABG 19-06-2021 11:45:AM
PH 7.34
PCO2 35.3
PO2 111
HCO3 18.6
St.HCO3 19.6
BEB -5.9
BEecf -6.0
TCO2 37.6
O2 Sat 96.5
O2 Count 18.2
COMPLETE URINE EXAMINATION (CUE) 19-06-2021 03:01:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
BLOOD UREA 19-
06-2021 03:01:PM
38 mg/dl 42-12 mg/dl
SERUM
CREATININE 19-06-
2021 03:01:PM
1.0 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 19-06-2021 03:01:PM
SODIUM 138 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, C l) 20-06-2021 11:24:AM
SODIUM 141 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 98 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, C l) 20-06-2021 10:27:PM
SODIUM 139 mEq/L 145-136 mEq/L
POTASSIUM 3.4 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
Treatment Given(Enter only Generic Name)
COV RTPCR, ABG, CUE, BLOOD UREA, SERUM ELECTROLYTES.
Name Value Range Name Value Range
SARS-COV-2
Qualitative PCR 19-
06-2021 11:38:AM
Negative ABG 19-06-2021 11:45:AM
PH 7.34
PCO2 35.3
PO2 111
HCO3 18.6
St.HCO3 19.6
BEB -5.9
BEecf -6.0
TCO2 37.6
O2 Sat 96.5
O2 Count 18.2
COMPLETE URINE EXAMINATION (CUE) 19-06-2021 03:01:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-4
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
BLOOD UREA 19-
06-2021 03:01:PM
38 mg/dl 42-12 mg/dl
SERUM
CREATININE 19-06-
2021 03:01:PM
1.0 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 19-06-2021 03:01:PM
SODIUM 138 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, C l) 20-06-2021 11:24:AM
SODIUM 141 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 98 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, C l) 20-06-2021 10:27:PM
SODIUM 139 mEq/L 145-136 mEq/L
POTASSIUM 3.4 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
Treatment Given(Enter only Generic Name)
Course in the hospital :This is a case of 55year old male with Heart failure with preserved EF with
k/C/o of DM and HTN with past history of CVA .The patient was started on Lasix infusion for 2 days
and patient lost about 7kgs of weight following Lasix infusion and patient shortness of breath was
reduced in 2 days and relieved symptomatically and advised discharge.The following treatment was
given day wise in the hospital.Day 1Inj LasixInj AugmentineDay 2Inj lasixInj panInj AugmentineInj
AzithromycinInj EcosprinDay 3AddedInj HydrocortDay 4Continuing same medication.
Advice at Discharge
1) Tab. Ramipiril 5mg PO/OD2) Tab.MET Xl 12.5mg PO/BD3) Tab.Lasix 40mg PO/OD.4) Tab.GLIMI
M1 PO/ BD.5) Tab Zincovit PO/OD.
Follow Up
review after 15 days to the OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS.
and patient lost about 7kgs of weight following Lasix infusion and patient shortness of breath was
reduced in 2 days and relieved symptomatically and advised discharge.The following treatment was
given day wise in the hospital.Day 1Inj LasixInj AugmentineDay 2Inj lasixInj panInj AugmentineInj
AzithromycinInj EcosprinDay 3AddedInj HydrocortDay 4Continuing same medication.
Advice at Discharge
1) Tab. Ramipiril 5mg PO/OD2) Tab.MET Xl 12.5mg PO/BD3) Tab.Lasix 40mg PO/OD.4) Tab.GLIMI
M1 PO/ BD.5) Tab Zincovit PO/OD.
Follow Up
review after 15 days to the OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS.
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