64 year old female with paroxysmal AF and COPD with type 3 PAH

64 year old woman presented to the casualty with the complaints of 

Dyspnea at rest since 1 week

Bilateral LL edema since 1 week 

Reduced urine output since 3 days


64 year old woman, housewife by occupation who says she has been experiencing dyspnea on and off along with cough since the past 13 years for which she has been using a rotahaler ( Formoterol plus Budesonide) and was told she had bronchial asthma. 

In 2016, she was admitted in an outside hospital for recurrent vomitings and pain abdomen. An upper GI endoscopy was done which revealed a large hiatus hernis and grade 2 esophagitis.

1 year back she was diagnosed with bilateral pneumonia for which she used medications for 2 months - history unclear 


She presented to casualty on Thursday with the complaints of dyspnea since 1 week which aggravated since 2 days along with bilateral pedal edema extending to knees, along with reduced urine output since 3 days


On presentation, she was an obese woman with central obesity, she was pale, tachypneic with a RR of 40cpm, PR of 200bpm, her BP was 130/70mmhg and GRBS - 150mg/dl

Spo2 at 97 % on RA

CVS - S1,S2 +

Lungs- Bilateral wheeze in all the lung fields 

Abdomen- Soft 

Bowel sounds + 


Her ECG showed a rate of 200, irregular with absent P waves C/o:-

 dyspnoea at rest since 1 week 

 B/l ll edema since 1 week 

 Abdomen distension and facial puffiness since 1        week 

Decreased urine output since 1 week 

H/o on and off fever with throat pain since 1 week 


Hopi:-

Patient was admitted for b/l pneumonia 1 year back for recurrent episode of vomiting and pain abdomen. She was taken to outside hospital and was diagnosed with large hiatus hernia and grade 2 esophagitis in 2016.


H/o past illness:-

K/c/o bronchial asthma since 15 years and has been on rotahale [formaterol + budesonide] 


Personal history:-

Decreased urine output 

Consumes 90 ml of whiskey every day since 35 years 

No significant family history 


General examination:-

Temperature:- 98.4F

Pr:- 200/min

Rr:- 40/ min

Bp:- 130/80 mm Hg 

Spo2:- 92%

GRBS:- 124mg%


Provisional diagnosis:-

Persistent AF secondary to valvular heart disease( MS and MR)

Rheumatic heart disease 


Treatment:-

On 25/6/21

- O2 supplement and maintain spo2 >92%

- INJ. Pantop 40 mg iv od 

- Tab DIgixin 0.25 mg po od at 8 am

- inj clexane 60mg SC 12th hourly 

- inj lasix 40mg IV bd 

- inj zofer 4 mg iv tid 

- nebulisation with budecort 6th hourly 

- monitor vitals pr and bp hourly 

- grbs charting 6th hourly 

- strict I/o charting 

- continuous ecg monitoring 

- inj ceftriaxone 1gm iv bd 


On 26/6/21

- Head end elevation 

- o2 supplement and maintain spo2 >92%

- inj ceftriaxone 1gm iv bd

- inj pantop 40 mg iv bd

- inj zofer 4 mg iv tid

- inj clexane 60mg SC 12 th hourly 

- inj lasix 20 mg iv bd 

- Tab digoxin 0.25 mg po od  

- tab amiadorone 10mg po od 

- nebulisation with budecort 6th hourly 

- continuous ecg monitoring 

- grbs charting 6th hourly 

- monitor vitals 

- strict I/o charting 

- syp lactulose 10 ml po tid 


On 27/6/21

- Head end elevation 

- o2 supplement and maintain spo2 >92%

- inj ceftriaxone 1gm iv bd

- inj pantop 40 mg iv bd

- inj zofer 4 mg iv tid

- inj clexane 60mg SC 12 th hourly 

- inj lasix 20 mg iv bd 

- Tab digoxin 0.25 mg po od  

- tab amiadorone 10mg po od 

- nebulisation with budecort 6th hourly 

- continuous ecg monitoring 

- grbs charting 6th hourly 

- monitor vitals 

- strict I/o charting 

- syp lactulose 10 ml po tid  th hourly 

- continuous ecg monitoring 

- grbs charting 6th hourly 

- monitor vitals 4th hourly 

- strict I/o charting 

- syp lactulose 10 ml po tid 


On 28/6/21

- Head end elevation 

- o2 supplement and maintain spo2 >92%

- inj ceftriaxone 1gm iv bd

- inj pantop 40 mg iv bd

- inj zofer 4 mg iv tid

- inj clexane 60mg SC 12 th hourly 

- inj lasix 20 mg iv bd 

- Tab digoxin 0.25 mg po od  

- tab amiadorone 10mg po od 

- nebulisation with budecort 6th hourly 

- continuous ecg monitoring 

- grbs charting 6th hourly 

- monitor vitals 

- strict I/o charting 

- syp lactulose 10 ml po tid  th hourly 

- continuous ecg monitoring 

- grbs charting 6th hourly 

- monitor vitals 4th hourly 

- strict I/o charting 

- syp lactulose 10 ml po tid 

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