A 75 year old Female patient with fever and SOB

A 75 year old female patient was presented to OPD with

Chief complaints:

Fever since 15 days

shortness of breath since 10 days

B/L pedel edema since 10 days

HOPI:

Patient was apparently asymptomatic 15 days back & then she developed fever  

which was insidious in onset, low grade, intermittent, 

with no aggrevating factors and relieved with medication. 

Fever was not associated with chills and rigor 

then she developed 

Shortness of breath since 10days which was 

insidious in onset, gradually progressed from grade 2-4 with no aggrevating factors and relieving factors.

Orthopnea present

C/o palpitations since 10 days, 

Bilateral pitting type of pedal edema since 10 days

extending upto knee,with no aggrevating and relieving factors. 

No history of chest pain

No history of syncope attack


Past History:

Not a known history of Hypertension, Diabetes mellitus,asthma,CAD,epilepsy 


Personal History:

Diet:mixed

Daily routine:

Daily she wakes up at 7AM does her regular activities,eats at 8AM and sits idle, Lunch at 12PM and sleeps afternoon at 1PM and wakes up at 4PM,Dinner at 7PM and goes to bed at 8PM

Appetite:normal

Bowel and bladder movements:normal

Sleep : decreased 

No addictions


Family History:

Not significant 


Treatment History:

Not significant


General Examination:

Patient is conscious coherent and cooperative and well oriented to time,place and person

Thin built and poorly nourished

Pallor: Present 





Pedal edema subsided (pic taken on 30/11/2022)

No signs of Icterus cyanosis, clubbing , Lymphadenopathy


vitals:

Temp: 98F

PR: 130-150 irregular 

Bp: 110/70 mmHg 

RR: 32 cpm


Systemic Examination:

CVS:

S1 S2 are heard

Barrel shaped chest

JVP raised 

Apex beat - diffuse

RS:

Barrel shaped chest , Trachea central

Normal vesicular breath sounds heard


Abdomen:

Soft and nontender

bowel sounds are heard

CNS:

No focal neurological defects


Investigations:
















X-ray:



ECG:
Missed P wave 
Rhythm Irregularly Irregular









Provisional diagnosis:

Atrial fibrillation+Heart Failure...?

COPD...?

Anemia with mild thrombocytopenia...?

Treatment:


On 25/11/2022

1 Packed RBC Transfusion done 


On 30/11/2022

1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION

2.INJ.LASIX 40 MG IV /BD IF SBP >= 110 MM OF HG

3. T.DILZEM 30MG PO/TID

4. T.ECOSPRIN AV 75/10 MG PO

5.T.ALDACTONE 25 MG PO/OD

6. T.DOLO 650 MG PO




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