63 yr old male with HFpEF secondary to CAD and hypertension and diabetes mellitus


TREATING TEAM:

Dr.Vijaya Lakshmi (Asst Prof)

Dr.Laxma Reddy (PGY3)

Dr.Manasa (PGY3)

Dr.Ajith (PGY2)

Dr.Durga Krishna (PGY1)

Interns:

Dr.Supriya

Dr.Mohitha

Dr.Sowmya

Dr.Amrutha 

Dr.Sanjay


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.



A 60 yr male agricultural worker from Akkinapalli came to casualty with C/o difficulty in breathing from 15 days,

C/o facial puffiness from 15 days,

C/o pedal edema from 15 days,

C/o decreased urine output from 15 days.


HOPI:

Patient was apparently asymptomatic 15 days back then he developed difficulty in breathing- grade 2(15 days back) — gradually progressed to grade 4  associated with palpitations and sweating. 

No H/O PND, orthopnea and chest pain.

C/O pedal edema (pitting type) from foot to knee from 15 days 

C/O decreased urine output from 15days.

No H/O burning micturition,hematuria.


PAST HISTORY:

Known chronic alcoholic since 10 years and stopped  2 weeks back (90 ml/day)

H/O ear surgery 4 yrs back at a private hospital.

K/C/O type 2 DM since 8 yrs on Tab GLIMI -M1 (500/1mg ) PO/OD 

K/C/O HTN since 8 yrs on TAB CLINIDIPINE 5 mg/OD on TAB DYTOR 10 mg/BD since 2 days 

No H/O smoking ,tobacco chewing.

No significant family history.


O/E 

Pt is conscious, coherent, cooperative.

General examination:

No pallor, icterus, clubbing, cyanosis, lymphadenopathy, pedal edema.

Facial puffiness +

VITALS

Temperature- afebrile 

Pulse rate 69bpm 

Spo2 98@ room air 

BP 160 /90 mmhg 

RR -22cpm


SYSTEMIC EXAMINATION:

CVS:

Inspection:

No visible impulses, no JVP elevation.

Palpation:

Apical impulse felt 1/2 inch medial to midclavicular Line 

Percussion:

All heart borders percussed.

Auscultation:

S1S2 +

No murmurs.

R/S: BAE +

P/A:  soft, nontender.

NS: NAD.


INVESTIGATIONS:






Serum Creatinine 

25/1/21- 0.9mg/dl

27/1/21- 1.4mg/dl

31/1/21- 1.9mg/dl

1/2/21- 1.8mg/dl


ECG




2D ECHO 




CARDIOLOGIST OPINION:




OPHTHALMOLOGIST OPINION:






PROVISIONAL DIAGNOSIS - 

HEART FAILURE WITH PRESERVED EJECTION FRACTION  

?SECONDARY TO CAD WITH HYPERTENSION AND TYPE 2 DIABETES MELLITUS.


TREATMENT:

1.Tab.LASIX 40mg /PO/OD

2.Tab.ECOSPIRIN-AV (75/10)/PO/OD

3.Tab.CLOPIDOGREL 75mg/PO/OD

4.Tab.CILNIDIPINE 10mg /PO/OD

5.Syrup GRILLINCTUS 2tsp /TID

6.Fluid restriction <1lit/day

7.Salt restricted diet.

8.Inj.HUMAN ACTRAPID INSULIN /sc 10-10-8 IU

9.BP, Pulse rate ,Spo2 monitoring 4 th hrly.

10.Strict I/O monitoring.

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