CBBLE UDHC SIMILAR CASES
A 60 year old male came to the OPD with the chief complaints of
Pedal edema since 3 months
SOB grade 4
Giddiness since 1 week
HOPI:
he was apparently asymptomatic 25 years ago and he was diagnosed to be diabetic as he had a history of loss of consciousness while he was going to washroom.
He was on irregular medication and stopped as sugars are normal.
Since 6 years he is on regular medication again.
*His Shortness of breath is aggravated on lying down and relieved on sitting position
H/O pedal edema 2 years back ,progressively increasing and pitting type.
SOB grade 4 since 1 year worsening since 1 week.
Not associated with palpitations,chest pain,sweating
H/O CAD in January and was diagnosed to be having ?MI
In February he presented to casualty in view of SOB grade III to IV.
K/C/O type 2 diabetes since 25 years on irregular medication
Past history:
*K/C/O hypertension 10- 12 years - irregular medication. using regularly since 8 years.
Using present medication since January on admission.
Personal history:
Diet- mixed
Appetite- normal
Sleep - adequate
Bowel and bladder movements: normal and regular
- alcoholic.90-180ml whiskey from 20 years of age weekly.
On examination:
Pt is conscious,coherent and cooperative.
Pallor - present
B/L pitting edema of legs
Vitals:
Afebrile
PR : 92bpm
RR: 24 cpm
BP: 130/80 mmhg
Spo2: 84%
94% on 6 litres of oxygen
CVS: s1,S2 heard
RS: B/L inspiratory crepts
P/A: soft, nontender
CNS:
Reflexes
Rt. Lt
B +2 +2
T +1 +1
S +1 +1
K +2 +2
A - -
Investigations:
ECG:
Hemogram:
Hb: 9.7
TLC: 9,300
Lymphocytes: 16
PCV- 28
PLT: 2.19
CUE:
Alb: ++
21/9/21
LFT:
TB: 0.73
DB: 0.20
AST: 19
ALP:273
TP: 7
ALB: 3.7
A/G ratio: 1.16
HBA1c : 7.1
RFT:
Urea: 132
Creat: 6.6
Na: 143
K: 4.6
Cl: 104
22/ 9/21
RFT:
Urea:136
Creat: 6.2
Na:144
K:4.3
Cl: 102
Provisional diagnosis:
HFpEF ( EF: 52%) with chronic renal failure
TREATMENT:
1.Propped up posture
2.O2 inhalation
3.Inj Lasix 50 mg iv / tid
4.Tab . Ecospirin AV PO/ OD
5.Tab. Carvedilol 3.125 mg PO/ OD
6.Tab.pan 40 mg PO/OD
Tab. Amlong 5 mg PO/ OD
7.Tab. Vildagliptin 50 mg PO/ OD
8.Fluid restriction <2 lit / day
9.Salt restriction <2 g / day
SOAP NOTES DAY 2
60 year old male with SOB and H/O CAD 8 months back
S-
Shortness of breath on daily activities
Generalised weakness
O-
Pt is c/c/c
Afebrile to touch
BP: 140/70 mmhg
PR: 80bpm
CVS: s1,S2 +
RS:BAE +,NVBS
P/A : soft, non tender,bowel sounds+
CNS: HMF intact
A: HFpEF with EF : 52% with chronic renal failure
P:
1.Propped up posture
2.O2 inhalation
3.Inj Lasix 50 mg iv / tid
4.Tab . Ecospirin AV PO/ OD
5.Tab. Carvedilol 3.125 mg PO/ OD
6.Tab.pan 40 mg PO/OD
Tab. Amlong 5 mg PO/ OD
7.Tab. Vildagliptin 50 mg PO/ OD
8.Fluid restriction <2 lit / day
9.Salt restriction <2 g / day
