case presentation heart failure
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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
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)
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
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
! 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