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
Pallor + , Bilateral Pedal edema +
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
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
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
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