A 60 yr old male with SOB
A 60 year old male came to casualty with C/o shortness of breath since 2 hours, grade 4,chest pain ,right sided since 2 hours, non radiating type , no h/o palpitations ,sweating.
He was apparently assymptomatic 25 years ago and then he was diagnosed to be diabetic ; he had H/o loss of consciousness while going to the washroom,he was on irregular medication and stopped as his sugars were normal.Since 6 years he is on regular medication.
2 years back h/o SOB , aggravated on lying and relieved in sitting position, H/o pedal edema increasing progressively and pitting type . SOB grade 4 since 1 yr , worsening since 1 week ,not associated with chest pain , palpitations ,sweating,H/o CAD in January and diagnosed ?MI .In February he presented to casualty i/v/o sob progressed from grade 3-4
K/c/o type 2 Diabetes since 25 years on irregular medication, since 6 yrs in regualr medication
K/c/o hypertension since 10years ,on irregular medication, regular medication since 8 years
Alcoholic- 90-180 ml whiskey
On general physical examination
Pt is c/c/c
Moderately built and nourished
Vitals -
Temperature - afebrile
BP- 140/90mm of hg
PR- 84bpm
Rr- 20 cpm
Spo2 - 96%on RA
Grbs- 190 mg/dl
Systemic examination
CVS - s1,s2 +
RS- BAE +, b/l inspiratory crepts present in the ISA, IMA.
CNS -NAD
P/A - soft,non tender
Provisional diagnosis- HFpEF with CRF
secondary to diabetic nephropathy, diabetic retinopathy (NPDR)
Grade 2 prostatomegaly
Serology- negative
Blood urea- 146 mg/dl
Serum creatinine - 6.4 mg/dl
Serum electrolytes-
Na- 141 mEq/l
K-4.1 mEq/l
Cl- 99 mEq/l
Plan of treatment -
Fluid restriction <1.5 L/day
Salt restriction <2 g/day
Inj. Lasix 49 mg iv bd
8am------4pm-----x
Inj.erythropoietin 4000units s/c weekly once
Tab.ecosprin-av (75/20) po h/s
x-------x-------8pm
Tab.cardivas 3.125 mg PO OD 8am
Tab.amlong 5mg po OD 8am
Tab.vildagliptin 50 mg po OD 8am
Tab.tamsulosin -d 0.4 mg op h/s 8pm
Propped up posture
O2 inhalation (to maintain spo2> 92%)
Grbs charting 6th hourly
Bp charting 4th hourly
OPTHAMOLOGY REFERRAL
Temperature charting
Soap notes day 1
S- sob decreased
O-
temp: afebrile
Pr- 79bpm
Bp-130/80
Grbs- 118mg/dl
CVS - s1,s2 +
RS- BAE +, b/l inspiratory crepts present in the ISA, IMA.
CNS -NAD
P/A - soft,non tender
A-
HFpEF with CRF
secondary to diabetic nephropathy
Grade 2 prostatomegaly
P- Fluid restriction <1.5 L/day
Salt restriction <2 g/day
Inj. Lasix 49 mg iv bd
8am------4pm-----x
Inj.erythropoietin 4000units s/c weekly once
Tab.ecosprin-av (75/20) po h/s
x-------x-------8pm
Tab.cardivas 3.125 mg PO OD 8am
Tab.amlong 5mg po OD 8am
Tab.vildagliptin 50 mg po OD 8am
Tab.tamsulosin -d 0.4 mg op h/s 8pm
Propped up posture
O2 inhalation (to maintain spo2> 92%)
Grbs charting 6th hourly
Bp charting 4th hourly
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