42 year old patient with alcoholic liver disease, heart faliure with cellulitis
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Note: This is an ongoing case, the E-LOG will be updated as and when we get the new information.
This case study was done under the guidance of Dr. Vamshi, Dr. Madhumitha
CHIEF COMPLAINTS:
A 42 year old male patient was presented to the casuality with chief complaints of:
- bipedal edema since 15 days
- fever and generalised weakness since 2 days
HISTORY OF PRESENTING ILLNESS:
A 42 year old male patient was presented to the casuality with chief complaints of:
- bipedal edema since 15 days
- fever and generalised weakness since 2 days
- shortness of breath since 2 days
No h/o pain abdomen, vomiting, loose stools
No h/o cough, chest pain
No h/o decreased urine output/ burning mictiurition and no other complaints
HISTORY OF PAST ILLNESS:
the patient had history of ulcer over left malleoli 10 days back followed by left lower limb swelling.
there is no known history of hypertension, asthma , epilepsy, coronary artery disease, TB
PERSONAL HISTORY:
The patient consumes 180 ml of alcohol per day and also kahini - 2-3 everyday since 20 years
GENERAL EXAMINATION:
the patient was conscious and coherrent
icterus: present
pedal edema: present - bilateral pitting edema
cyanosis: absent
pallor: absent
clubbing: absent
lymphadenopathy: absent
VITALS:
TEMPERATURE: 98.6 F
BP: 100/70 mmHg
PULSE RATE: 80 bpm
RESPIRATORY RATE: 18 per min
SYSTEMIC EXAMINATION
CVS:
- Apex beat : visible, diffuse shifted down and out
- Palpable p2+
- Parasternal heave + (grade 3)
- S1 , S2 + heard
- no murmurs
- jvp: elevated
- raised jvp
- visible apex beat
RESPIRATORY SYSTEM:
- Barrel shaped chest
- BAE+
- Crepts + right sided lung fields
barrel shaped chest
- soft and non tender
CNS:
- no focal neurological deficits
INVESTIGATIONS:
1.) chest xray : 1/7/21
2.) ECG
on 1/7/21
on 3/7/21
Atrial fibrillations seen
on 5/7/21
on 7/7/21
3.) blood urea: 1/7/21
5.) serum electrolytes: 1/7/21
6.) liver function tests: 1/7/21
7.) hemogram: 1/7/21
8) complete urine examination: 1/7/21
9.) 2D Echo: 1/7/21
1.) hemogram : 5/7/21
2.) serum electrolytes 5/7/21
3.) serum urea 5/7/21
4.) serum creatinine 5/7/21
DIAGNOSIS:
HEART FALIURE WITH REDUCED EJECTION FRACTION (HRrEF) secondary to coronary artery disease, with bilateral plural effusion, acute kidney infection (AKI) - CRS 1, Left lower limb cellulitis , alchoholic liver disease, lowerlobe pheumonia and ?emphysema
TREATMENT:
on day 1 : 2/7/21
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 12.5gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
on day 2 : 3/7/21
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaxone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 12.5gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
on day 3: 4/7/21
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaxone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 25 gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
- tab digoxin 0.25 mg stat
on day 4 : 5/7/21
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaxone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 25 gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
- tab digoxin 0.25 mg stat
on day 5: 6/7/21
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaxone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 25 gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
- tab digoxin 0.25 mg stat
- inj clindamycin 600 mg IV/TID
- fluid restriction < 1 lt/day
- salt restriction < 2gm/day
- inj. cetriaxone 1 gm IV/BD
- tab. lasix 40 mg BD
- tab. MET-Xl 25 gm BD
- BP / PR/ Temp/ Spo2 monitoring
- tab. aithromycin 500mg OD
- tab. Ecosprin- av 75/20 mg
- tab digoxin 0.25 mg stat
- inj clindamycin 600 mg IV/TID
this is an ongoing case, E-LOG will be updated as and when we get the new information
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