Subjective data Chief Complain SOB and limbs edema

Subjective data • Chief Complain： SOB and limbs edema progression for half a month. WHAT may cause these symptoms?

Objective data • Present illness: According to the description from the patient and her family, this 78 -year-old woman who has history of VHD with CHF; arrhythmia post PPM implantation; hypertensive cardiovascular disease and gout with medication treatment at our CV OPD. This time she WHAT is the definition of CHF? suffered from SOB and limbs edema progression for half a month. She denied dizziness, chest pain, chest tightness, cold sweating, nausea or vomiting. Due to above symptoms persisted, she went to our CV OPD for help. Under the umpression of CHF Fc II-III and limbs edema. She was admitted to our ward for further evaluation and management.

O • Past history: 1. History of other systemic diseases: VHD with CHF Arrhythmia post PPM implantation HCVD Gout 2. History of major operation or trauma: Arrhythmia post PPM implantation 3. Allergy to food or drugs: denied

O • Personal history: 1. Habit of cigarette smoking: denied 2. Habit of alcoholic drinking: denied 3. Occupation: nil 4. Denied recent traveling history • Family history: As pedigrees

O • Review of systems: 1. Positive findings: shortness of breath, limbs edema. 2. Negative findings: fever, chills, dizziness, headache, dysphasia, night sweating, cough, sputum, orthopnea, hemoptysis, epistaxis, chest pain, abdominal pain, anorexia, dysphagia, nausea, vomiting, constipation, WHY we need Negative findings? diarrhea, hematemesis, hematochezia, melena, dysuria, oligouria, body weight loss.

O • Physical examinations: Vital signs: BP: 122/48 mm. Hg, BT: 36. 1 C, PR: 67/min, RR: 18/min General appearance: ill-looking Conscious: alert Mentality: intact to JOMAC, GCS: E 4 M 6 V 5 Skin: no petechiae, ecchymosis, normal skin turgor HEENT: grossly normal, no pale conjunctiva, no icteric sclera Neck: supple, no jugular vein engorgement, no carotid bruits, no Goiter Chest: symmetrical and free expansion, coarse and rales of bil breathing Vital sign、外觀、意識、皮膚、頭部、頸部、胸、心、腹、背、下肢(運動能力)、神經學 sound, no wheezing Heart: PMI over midline of left clavian, 5 th intercostal space, regular heart beats, systolic murmur, no S 3, no S 4 Abdomen: soft and flat, normoactive bowel sound, Liver/Spleen: impalpable, no Murphy's sign, no shifting dullness, no tenderness or no rebounding pain Back: no spine deformity, no CV angle knocking pain Extremities: freely movable, limbs pitting edema grade 2 -3 Neurological examinations: essentially negative

O • General lab. data • Special lab. data • X-ray data

Analysis • Impression: 1. Valvular heart disease with congestive heart failure, New York Heart Association Functional class II-III 2. Cardiac arrhythmia post permanent pacemaker implantation 3. Hypertensive cardiovascular disease 4. Gout

Plan • Diagnostic plans: 1. Check B/R, SMA, PT/APTT and BNP 2. Arrange cardiac echo • Therapeutic plans: 1. Rasital iv form 2. NTG iv pump drip 3. Keep OPD oral medications 4. On EKG monitor 5. Record I/O and BW Qd • Educational plans: 1. Explain the present condition & following treatment direction to patient and family in detail. 2. Water and salt restriction.

EKG

X-ray 2015/11/02 V. S 2015/11/09

修改用藥策略 • • GENDOBU：Dobutamine：升壓 CCB：降低左心室作功 Spironolactone：保鉀型利尿劑 LANOXIN：digoxin ORFARIN：warfarin NTG：nitrate Albumin：提高血管內膠體壓，拉回組織間液

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