63 yr old Female with Heart failure with AF with reduced ejection fraction and is K/C/O DM since 15 yrs

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Case presentation:

A 63 yr old women who is an housewife came to OPD on 22/12/2020 at 10:45 am with 

C/O bilateral pedal edema since 15 days 

       Sob since 15 days 

       Decreased appetite since 10 days

       Decreased urine output since 10 days 

       Pain during swallowing since 10 days 

      Pt was apparently asymptomatic 15 yrs back then 

In 2005- one day she had fever and giddiness for which she went to hospital and there she was diagnosed to be Diabetic ( Type 2 Diabetes mellitus)intially on insulin for first  1 yr then next was on metformin 500 mg and glimepiridine 1 mg 

Then Since 2015 she had on and off sob ( Grade 1) orthopnea present , PND present, sob  aggrevated in winter season ,relieved on medication ( theophylline and etiophylline) it was associated with palpitations. she also had on and off complains of chest pain

In 2018 she had complains of decreased hearing And also complaint of ear pain which relieved on medication ( otogesic)

And now in 2020 She complains of bilateral pedal edema since 15 days initially it was upto Ankle and then extended upto knee, it is of pitting type 

℅acute accerbation of sob since 15 days (sob- initially( 5yrs back) it was grade 1 and now progressed to grade 4 ) associated with orthopnea PND  and palpitations

 Decreased urine output since 10 days

Decreased appetite since 10 days 

Pain during swallowing since 10 days

H/o fever 3 days back for 1 day which was high grade intermittent not associated with chills or rigors , relieved on medication

No H/o cough and cold ,ear discharge, ringing sensation,throat pain , burning micturition,loose stools , vomitings, constipation, headache .

PAST HISTORY

Known case of type 2 DM since 15 yrs , intially on insulin for first  1 yr then next was on metformin 500 mg and glimepiridine 1 mg 

No H/O HTN, CAD, CVA, Asthama, TB

PERSONAL HISTORY: 

Diet- mixed 

Appetite: decreased since 10 days 

Bowel:  regular 

Bladder- decreased since 10 days

FAMILY HISTORY:

No history of DM , HTN, CAD, CVA, Asthma in the family

GENERAL EXAMINATION

Patient is conscious, coherent,non  cooperative 
Pallor + , Bilateral Pedal edema +
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
 

Super numerary fingers and toes  seen on both hands and toes

Blebs seen on Right lower limb

A ruptured bleb which developed into an ulcer seen on dorsum of right foot

VITALS:

TEMPERATURE: 98.9F
PULSE: 80bpm
RESPIRATORY RATE - 19cpm
BP: 110/70mm of hg
SPO2: 98%

GRBS: 88 mg/dl

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:  

Apex beat at 6 th intercostal space ( 2cm lateral to mid clavicular line)

Heaving apex

Peripheral pulses not felt 

JVP - RAISED

S1 , S2 HEARD 

MUFFULED HEART SOUNDS

RESPIRATORY SYSTEM: 

BAE+,NVBS,  B/L infrascapular and infraaxillay crepitation+

PER ABDOMEN: Obese, soft,non tender , no organomegaly

CNS : 

NAD

PROVISIONAL DIAGNOSIS

HEART FAILURE WITH AF WITH REDUCED EJECTION FRACTION AND IS A K/C/O DIABETES MELLITUS SINCE 15 YRS

INVESTIGATIONS 

DAY 1

HAEMOGRAM

LFT 

RFT 

PT , INR 

ABG 

FBS 

GLYCATED HAEMOGLOBIN

CHEST XRAY

ECG 

At 12 pm

At 4 pm 

2D ECHO 

DAY 2

ABG

ECG

DAY 3 

CUE

ECG 

AT 6 am

ABG 

DAY 4

PATIENT EXPIRED AT 7: 34 am 

ECG

TREATMENT

DAY 1

1) Fluid restriction < 1.5L per day

2)INJ AMIODARONE 1.5 mg bolus followed by 20ml/hr ( 1mg / min) x 6 hrs followed by 10ml/hr( 0.5mg/hr) x 18 hrs

3) INJ LASIX 40 mg IV / TID if systolic blood pressure > 110mmhg

4) INJ HAI s/c TID according to sliding scale( 8am--2pm--8pm)

DAY 2

1)Head end elevation O2 supply if spo2 < 90%

   Fluid restriction < 1.5L per day

   Salt restriction < 2gm/ day

2)INJ AMIODARONE 1.5 mg bolus followed by 20ml/hr ( 1mg / min) x 6 hrs followed by 10ml/hr( 0.5mg/hr) x 18 hrs

3) INJ LASIX 40 mg IV / BD if systolic blood pressure > 110mmhg

4) INJ HAI s/c TID according to sliding scale 8am---- 2pm-----8pm

5) WAXONLY EAR DROPS 3 drops 4 times for 1 week

6) FUSIDIC ACID CREAM for local application 3 times/day

7)SYP. LACTULOSE 10 ml PO / BD morning and night

8)TAB.MET - XL 25mg PO/ OD ( morning)

9) TAB. CLOPITAB 75mg at 2pm

10)TAB. ATORVAS 40 mg H/S

11)TAB. ALDACTONE 25mg OD

12)TAB. CARVIDAS 3.125 mg half tablet BD

13) FOLEY'S CATHETERIZATION DONE

DAY 3

1)Head end elevation O2 supply if spo2 < 90%

   Fluid restriction < 1.5L per day

   Salt restriction < 2gm/ day

2)INJ AMIODARONE 1.5 mg bolus followed by 20ml/hr ( 1mg / min) x 6 hrs followed by 10ml/hr( 0.5mg/hr) x 18 hrs

3) INJ LASIX 40 mg IV / BD if systolic blood pressure > 110mmhg

4) INJ HAI s/c TID according to sliding scale 8am---- 2pm-----8pm

5) WAXONLY EAR DROPS 3 drops 4 times for 1 week

6) FUSIDIC ACID CREAM for local application 3 times/day

7)SYP. LACTULOSE 10 ml PO / BD morning and night

8)TAB.MET - XL 25mg PO/ OD ( morning)

9) TAB. CLOPITAB 75mg at 2pm

10)TAB. ATORVAS 40 mg H/S

11)TAB. ALDACTONE 25mg OD

12)TAB. CARVIDAS 3.125 mg half tablet BD

13) TAB . DILTIAZEM 30 mg PO/ TID

DAY 4

PATIENT EXPIRED AT 7: 34 am ON 25/12/2020  DUE TO SUDDEN CARDIAC ARREST