Case presentation heart failure

Case presentation

Date:2014/12/09 Doctor: 謝宜璋醫師 PGY: 郭政諺醫師

Patient Profile

!   Chart Number:21628067

!   Name: 曹O傑

!   Gender: Male

!   Age: 87 (1972/10/08)

!   Height: 160cm

!   Weight: 46.9kg

!   BMI: 18.3

!   Admission date: 2014/12/06

!   Admission condition T: 36.9°C P:82/min R:16/min BP: 126/68 mmHg

Chief Complaint

!  Progress bilateral legs edema for two days

Present Illness

!   ER: short of breath, dizziness, T: 36.6°C, HR: 110/min, BR:18/min, BP:115/58mmHg

!   No systemic disease before

!   Legs pitting edema - gradually onset and persisted for two days - bilateral, grade +++ - no local heat, skin lesion - associated symptoms: weakness, pale, short of breath Negative finding - No fever, No nausea/vomiting, No chest pain, No OP history, No decreased urine, No other edema, No tarry nor bloody stool, No taking new drugs

Personal History

!   Allergy: No Known Allergy

!   Travel History: Nil

!   Occupation: Nil

!   Contact: Nil

!   Cluster: Nil

! Betelnut (Denied)

!   Smoking (Denied)

!   Alcohol (Denied)

Family history

23 yr

No DM, HTN, Mailgnancy family hsitory

Past History

!   1.Pulmonay TB post-anti-tberculosis therapy history

!   2.Osteoporosis with old T10 T12 L2 L3 compression fracture

Physical examination Pale conjunctiva and lips Dry lips and tongue

Smooth breath pattern Coarse breathing sound

Bilateral limbs pitting edema

Irregualr heart beat Systolic heart murmur

Abdomen soft, No tenderness, No enlarge liver border Tympanic percussion sound

No skin lesion, No visible varicose

Chest X-ray

EKG

Laboratory Examination ! Hemogram

Laboratory Examination

Urine Analysis

Impression

!   1) Anemia, microcytic cause to be determined R/O GI loss

!   2) Congestive heart failure,NYHA FcIII

!   3) Osteoporosis with old T10 T12 L2 L3 compression fracture

!   4) Malnutrition

!   5) Bilateral hearing impairment

Plan

!   1) Diagnostic: -Microcystic Anemia Examination stool ob, Arrange Pandoscope, Survey tumor marker - Heart failure Arrange 2D cardio echo Find the reason caused heart failure

!   2) Treatment: - Blood transfusion - Fe support

!   3) Discharge plan - Find the reason of GI bleeding and mangement - Find the risk factor of Heart failure and educated patient - Vital sign stable with stable clinical appearance

Treatment course !   Anemia

Treatment course

!   Anemia

Treatment course

!   2014/12/8~9

! Hb: 3.9 g/dl à 8.5 g/dl (blood transfusion 5U) with stable vital sign, no dyspnea, no dizziness now

!   Wait for 2D echo and Panendoscope

Thanks for your listening