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The WHo? - Coggle Diagram
The WHo?
Initial data
Age
52
Gender
male
marital status
socio-economic status
Occupation
nationality
weight
81
height
191
Initial diagnosis
Presenting complaints
shortness of air
dyspnoea
edema of lower extremities
HTN 200/100mmHg
HR 90-95
pO2 86% -
Orthopnoea
lower extremity edema 1/3rd of leg
ECG
sinus, regular, left axis dev., V.extrasys.,
Dynamics
after 1 day
BP 160/90
Fatigue and shortness of breath
HR 76 - 80
Dull vesicular sounds and rare wet wheezes
after 2 days
BP 170/90
HR 70-75
Dull vesicular sounds and rare wet wheezes
pO2 94%
on 5th day
worsening of symptoms
vertigo
falling
sign of blood in his nose
BP 150/100
HR 88
SpO2 94
on 6th
BP 160/90
HR 70-75
SpO2 91
Final diagnosis
dilated cardiomyopathy
NYHA III
Ventricular arrythmia LOWN 3-4
hydrothorax
CKD
Investigations and tests
heart US
eccentric dilation of LV
right ventricle dilation and decreased constrictive function TAPSE 1.3cm
thickened aorta and dilation on ascneding
mitral valve calcification
EF 15-20%
IVC congestion 2.5cm
doppler: 2nd type diastolic dysfunction / 1st defree MR / PHTN 1-2 degree
hypertensive LA
minimal fluid in right pleura
blood analysis
Treatment
Initial plan
aspirin 0.5
amlodipine 5ml
omeprazol 20
amprilon 10
furosemid 40 then 20
NaCl 0.9
PMH/PSH
hypertension