28 year old male with pedal edema and SOB

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Case presentation:28 year old male who is a coal worker came with chief complaints of palpitations followed by SOB  since 1 week and pedal edema since 4 days.

Apparently normal 1yr back, developed symptoms of neck pain and giddiness,so he consulted a local doctor and he was diagnosed with hypertension with bp-160/100mmhg for which he used the medications given by the doctor for two days and discontinued the medications as the bp was recorded normal as advised by his doctor.

He came to our OPD with complaints of-Palpitations sudden in onset , no aggrevating and releving factors then he developed SOB at rest (grade-4) since 7 days ,gradual onset progressive in nature ,aggrevated with work later he developed pedal edema bilateral till knee sudden in onset which gradually progressed to thigh 2days, relieved on limb elevation 

Past history : 

 h/o of hypertensive since 1yr 

No h/o  dm , asthmaa

No similar complaints in the past .

Family h/o: 

His mother is known case of diabetic , hypertensive and hlo of stroke ( paraplegia)

Personal h/o :sleep adequate 

Diet mixed 

Addictions : Regular intake of 180 ml whiskey since 1 nd 1/2 year

On examination -

Pt is c/c/c 

There are no signs of pallor ,icterus ,cyanosis ,clubbing,

Bilateral pitting type of pedal edema is present upto groin region

His vitals : afebrile

Bp - 160/70 mmHg

Pulse - 90 BPM

RR - 22cpm

GRBS - 117 mg %

Spo2 - 96%

Jvp raised 

Systemic : 

P/A : 

Shape of abdomen : obese 

no scars , sinuses ,no distended veins ,hernial orifices free ,soft 

No tenderness 

RS :nvbs heard 

No added sounds 

CNS : NAD

CVS  :

S1 S2 heard 

S3 gallop present 

Parasternalheave

JVP raised above the angle of mandible 

Day1-

Investigations ordered  : 

HEMOGRAM : 

RFT: 

LFT:

USG ABDOMEN: 

CUE:

2D ECHO : 

CHEST X RAY : 

Treatment given : 

PROPPED UP POSITION 

INJ PANTOP 40 MG /IV / OD 

INJ LASIX 40 MG /IV / TID 

I/O CHARTING 

DAILY WEIGHT MONITORING 

BP/ PR HOURLY 

Provisional diagnosis on admission: 

Heart failure with preserved ejection fraction (EF -60%)

Day 2-

No fresh complaints 

Orthopnea - decreased 

PND -decreased 

SOB - decreased

O/E : 

Patient is C/C/C well oriented to time , place , person 

Pallor +

No signs of icterus ,cyanosis , clubbing, 

Lymphadenopathy, edema 

Vitals : afebrile 

BP - 160/80 mmhg 

PR - 97 bpm

GRBS - 123 mg %

Weight : 74 kg

 Fever - absent

I/O - 400/2800ml

CVS - loud S1 , parasternal heave present pansystolic in tricuspid area .

RS - BAE + 

P/A - soft , non tender

CNS - NFND 

Investigations 

ECG

Treatment given: 

PROPPED UP POSITION 

INJ PANTOP 40 MG /IV / OD 

INJ LASIX 40 MG /IV / TID 

I/O CHARTING 

MAINTAIN SPO2 more than 95%

DAILY WEIGHT MONITORING 

BP/ PR HOURLY 

FLUID RESTRICTION less than 1 lit /day , salt restriction less than 2gm / day 

TAB ECOSPRIN 75 MG OD 

TAB ALDACTONE 50MG OD 

INJ THIAMINE 100MG /IV / BD 

Diagnosis- 

Heart failure with preserved ejection fraction

Day 3 

No fresh complaints 

O/E : 

Patient is C/C/C well oriented to time , place , person 

Pallor +

Edema + 

No signs of icterus ,cyanosis , clubbing, 

Lymphadenopathy

Fever - absent

Weight - 73 kg 

I/O - 700/900 

Stools - passed 

Vitals : afebrile 

BP - 150/120 mmhg 

PR - 103 bpm

GRBS - 112mg %

Weight : 74 kg 

CVS - S1 ,S2 + ,S3 in tricuspid area  parasternal heave

RS - BAE + 

P/A - soft , non tender.

CNS - NFND 

Treatment given: 

PROPPED UP POSITION

INJ PANTOP 40 MG /IV / OD 

INJ LASIX 40 MG /IV / TID  

INJ THIAMINE 100MG /IV / BD 

TAB ATORVAS 20 MG H/S

I/O CHARTING 

MAINTAIN SPO2 more than 95%

DAILY WEIGHT MONITORING 

BP/ PR HOURLY 

FLUID RESTRICTION less than 1 nd half lit /day , salt restriction less than 2gm / day 

TAB ECOSPRIN 75 MG OD 

TAB ALDACTONE 50MG OD 

TAB RAMIPRILL 5NG OD - 8AM 

Diagnosis : Heart failure with preserved ejection fraction with denovo