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
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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
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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