Writing A Summary

Mr. PS, a 58 year old Indian male, is a known hypertensive, diabetic and has been previously diagnosed with congestive cardiac failure secondary to a right bundle branch block in 2012.

He presented to the emergency department complaining of productive cough and worsening shortness of breath associated with palpitations for the past 2 days. He admitted to not being compliant to his medications and fluid restriction which has been attributed as the cause of his current presentation. In the past 2 years, he has had been admitted 2 times with the same presentation and has defaulted his appointment with the cardiologist in the last year. He is classified as NYHA class 2 .

On examination, he did have a raised jugular venous pressure and bilateral pitting edema up to his mid-shin. Examination of his cardiovascular system revealed normal heart sounds devoid of murmurs with a deviated apex beat possibly indicative of cardiomegaly. There was also bilateral basal coarse crepitation’s and reduced air entry noted upon auscultation of lungs.

Importantly, an acute myocardial infarction was ruled out by the investigations performed at the emergency department. Chest x-ray revealed signs of pulmonary congestion were indicative of pulmonary edema.

A diagnosis of acute exacerbation of Congestive Cardiac Failure secondary to noncompliance or restriction of fluid with hypertension and diabetes was made.

He was admitted to ward 3 for 4 days and was subsequently treated with IV furosemide, anti-heart failure medications coupled with fluid and diabetic diet with salt restriction. He was discharged after 4 days after conditions had improved over the 4 days as he did not complain of shortness of breath or palpitations. His bilateral pedal edema was also still present but he was able to sleep at night.

Upon discharge his vital signs were stable. He did not complain of symptoms suggestive of poor tissue perfusion such as giddiness or warm skin.

He was discharged with the medications as noted and was given an appointment to follow up in the medical outpatient department unit. An appointment for a repeat echocardiogram was made in a month with a cardiologist and was also told to return to the medical outpatient department in 3 months’ time for follow up. He was also reminded to be compliant to his medication and was referred to a dietician upon discharge.

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