A 62-year-old man with a history of diabetes, hypothyroidism, COPD, OSA, and CAD presented with shortness of breath for 4 days that progressed from NYHA Class 2 to 4, along with orthopnea, dry cough, and pedal edema. On examination, he was afebrile with tachycardia, hypotension, tachypnea, and hypoxia. He was diagnosed with acute decompensated heart failure with severe respiratory distress, hypoxia, and hypotension.
2. A 62 years old gentleman came to ER with
Complaints of
Cough - 4 days
Shortness of Breath – 4 days
H/O Present illness:
-SOB started 4 days back , initially associated with
normal phsysical activity and progressed to at rest
also.
-H/O Orthopnea present
-No H/O PND
-No H/O Chest pain, Palpitations, Syncope.
-H/O pedal edema on and off present.
3. -Cough started 4 days back. Dry cough. More during
night time.
-No H/O Hemoptysis
-No H/O Fever
-Bowels and Bladder functions are normal.
Past History:
-H/O DM – 28 yrs, Hypothyroidism, COPD, OSA on
home BiPAP, CAD- Triple vessel disease on medical
management.
-H/O previous hospitalisations present with similar
complaints present
-H/O Cholecystectomy 20 years back
4. Medication History:
- Tab Amaryl M2 forte PO BD
- Tab Corbis PO OD
- Tab Lasix 20 mg PO OD
- Tab Rosalet 20/75 PO OD
- Tab Thyronorm PO OD
- Tab Nikoran PO BD
Personal History:
- Married
- Takes vegetarian food
- No H/O alcoholism intake, smoking, Tobbaco or
Beetelnut Chewing.
- No Food and Drug allergies
5. SUMMARY:
A 62 years old gentleman with H/O DM,
Hypothyroidism, COPD, OSA with home BiPAP,
CAD – Triple Vessel Disease on medical
management with recurrent CHF came to ER
with C/O Shortness of Breath, started 4 days
back, progressed in severity from NYHA Class 2 to
NYHA Class 4, with H/O Orthopnoea, Dry cough
more during night time and Pedal edema.
6. General Examination:
Patient is well built and well nourished.
• Conscious/coherent
• Afebrile
• No pallor
• No cyanosis
• No clubbing
• No icterus
• No generalized lymph adenopathy.
• B/L Pedal edema present
• JVP raised ( 6 cm of H2O above the sternal angle)
7. Vital signs:
- Temp: 98.4 F
-PR : 120/min; regular rhythm, low volume
-BP: 82/48 mm Hg left arm supine position
- RR: 32/min
-Spo2: 60 with room air
8. Systemic examination
Inspection:
• No Engorged neck veins
• Visible pulsations over neck +
• Trachea appears to be in midline.
• No visible scars & swellings over the chest &
precordium
• Chest normal in shape
• Chest expansion appears to be equal
• No intercostal recession
• Use of accessory muscles of respiration present
• Cardiac impulse appears to be in left 5th intercostal
space in the mid-clavicular line.
9. Palpation:
• Tracheal position conformed in midline
• No palpable swellings over chest
• No tenderness over chest
• Chest expansion B/L equal.
• Cardiac impulse: left 5th intercostal space in the
mid-clavicular line.
• No other palpable pulsations
• No palpable murmur
10. Percussion:
• Resonant note present over all areas of the lung
Ausculation:
-B/L air entry present and equal
-B/L Crepitations present
-1st and 2nd heart sounds present.
- No murmurs
