HFPEF - Acute decompensated heart failure

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A 60-year-old male patient resident of bhongiri came to the OPD with chief complaints of shortness of breath (grade3-4 according to NYHA classification )since yesterday ;complains of abdominal distension since yesterday ,decreased urine output since yesterday , B/l Pedal edema since Yesterday and burning micturition since two days .

History of presenting illness: –
Patient was apparently a symptomatic till yesterday then he developed shortness of breath (grade3-grade4) according to NYHA with Orthopnoea not associated with PND , Palpitations chest pain.
Complains of abdominal distension not associated with nausea or vomiting.
Complains of bilateral Pedal edema of pitting type up to the knee.
Complains of decreased urine output since yesterday complains of burning micturition.


Known case of alcohol Consumption – occasionally(once a week- 90ml whiskey)
k/c/o htn on irregular medication
Not a known case of diabetes mellitus 
past history:- 
he was admitted in july 2020 with similar complaints and was diagnosed with acute decompensated heart failure with moderate MR.
He stopped his medications since 3 months.
Personal history: –
Marital status-married
Appetite – normal 
Diet-mixed
Bubble and bladder – regular
Addictions – alcohol consumer occasionally, stopped since one year.
No Known allergies.
Family history: –
Insignificant
General physical examination –
Patient is conscious coherent and cooperative and examine well lit room.
Pedal edema : ++
No signs of pallor, Cyanosis, clubbing, Icterus, lymphadenopathy .
Temperature : 98.5° F
Pulse rate: 94 BPM
Respiratory rate: 18 cycles per minute
BP: 120/ 70 mm of Hg
Spo2: 96%
Grbs : 115mg%
CVS:-S1, S2 heard ; Pan systolic murmur heard in mitral area.
apex beat: left 5th ics
elevated jvp
orthopnea:+
no thrill
pulse: rate:94bpm
            rhythm: regularly irregular

Respiratory system: –
Dyspnea: present (grade3-4)
Position of trachea – Central
breath sounds – BAE plus
Crepitations heard in lt. MSA, IAA
Per Abdomen: –
Shape of the abdomen – obese
Tenderness – absent
No palpable mass , no organomegaly
Hernia notifies intact, no free fluid ,no bruits.
bowel sounds : present

Central nervous system examination –:
Level of consciousness – alert
Speech-normal
No signs of Meningeal 
Reflexes normal.
 
ecg findings:. inverted p waves in lead 1 ,2 ,3 and ventricular premature complexes seen in V4, V5, V6.
junctional rhythm with occasional vpc.

Provisional diagnosis:- acute decompensated heart failure

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