A 50YR OLD MALE with Dilated cardiomyopathy secondary to ?CAD with ejection fraction 28 %
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 50 yr old male ,daily wage labourer by occupation came to the casualty with complaints of pedal edema since 2 months , decreased urine output since 15 days , abdominal distension since 15 days and SOB since 15 days
He was apparently alright 3 yrs ago and was then diagnosed to be diabetic and on OHA'S
patient complaints of pedal edema since 2 months , aggravated to above knees and not subsiding since 15 days
a/w decreased urine output since 15 days aand break in the stream of urination
c/o abdominal distension since 15 days
c/o chest pain on and off since 15 days ,non radiating,not a/w sweating or giddiness
c/o sob since 15 days grade 3 progressed to grade 4 a/w orthopnea and PND
patient went to outside hospital was put on foleys -clear urine f/b hematuria in foleys
past history :
k/c/o DM on OHA 'S (unkown)
not a k/c/o HTN ,CAD.
h/o deviation of mouth to left since childhood
personal history:
appetite-normal
bowel movements-regular
micturition - normal
addictions- alcohol 1-2 times /week (90ml ) since 10 yrs
smoking: 1 pack/day (10/day) - beedi since 10 yrs
On General Examination:
no pallor ,icterus,cyanosis , clubbing, lymphadenopathy
edema of feet - B/L
temp: 98F
pulse : 100/min
respiration: 22 /min
BP left arm : 110/70 mmhg
sp02: 98%
GRBS: 177 mg/dl
CVS
JVP : elevated
s1,s2 heard
RS: BAE + ,B/L IAA ,ISA crepitations +
abdomen :
shape - obese
soft,and non tender.
CNS:NAD
Investigations:
Investigations :
17/11/21:
18/11/21:
19/11/21:
provisional diagnosis:
Dialated cardiomyopathy secondary to ?CAD
ejection fraction 28 %
Treatment:
1.propped up Posture
2.Fluid restriction to <1.5Lt / day
3.Inj Lasix 40mg/IV/BD
4.Inj Human actrapid /SC (based on the grbs levels)
5.Inj thiamine 2amp in 100ml NS/IV/BD
6.Tab Ecospirin AV 75/20mg PO/OD
7.Strict Grbs monitoring 6th hourly
8.O2 inhalation (if spO2<92%)
9.Daily weight monitoring
10.I/O monitoring
Soap notes:19/11/21
S-sob decreasedsed since last night,increased on straining for stools yesterday,
scrotal swelling+
orthopnea resolved.
O-conscious,coherent ,appears tachypneic
?keloid scar present
pes cavus of right foot
pedal edema+(b/l )
afebrile
PR-105/min
BP-130/80mmhg with inj dobutamine @3.6ml/hr.
CVS-JVP-raised upto angle of mandible
apex best seen and felt at left 6th ICS in annterior axillary line
parasternal heave in left side
S1,S2+,pansystolic murmur in pulmonary tricuspid areas
R.S-BAE+,end inspiratory coarse crepts in left LL area
P/A-distended,non tender
CNS-hmf intact
ptosis of left eye and deviation of angle of mouth to left(since 4years of age)
GRbs 18/11-8am-88mg/dl,2pm- 146,8pm-174 mg/dl -4IU HAI given
input/output=1560/2950ml
red coulered urine ?haematuria
cue sent report awaited.
A-Dilated cardiomyopathy secondary to ?CAD
with EF-28%
severe TR with PAH
diabetic
LMN facial palsy on left side since 4years of age.
P-1)propped up position
2)fluid restriction to <1lit /day
3)salt restriction <2g/day
4inj lasix 80mg in 50ml ns @5ml/hr
5)inj dobutamine250mcg in 50ml ns @3.6ml/hr
6)tab ecosprin av 75/20mg /po/od
7)grbs 6th hourly premeal
8) inj hai s/c tid
9)syp cremaffin plus 10ml/po/hs
10) avoid strenuous activity.
Soap notes:20/11/21
scrotal swelling+
orthopnea resolved.
dry cough+
O-conscious,coherent
?keloid scar present
?pes cavus ?cauda equinus with varus of right foot
pedal edema+(b/l )
afebrile
PR-92min
BP-130/80mmhg with inj dobutamine @2.5ml/hr.
CVS-JVP-not raised compared to yesterday.
apex best seen and felt at left 6th ICS in annterior axillary line
parasternal heave in left side
S1,S2+,pansystolic murmur in pulmonary tricuspid areas
R.S-BAE+,end inspiratory coarse crepts in b/L LL
P/A-distended,non tender
CNS-hmf intact
ptosis of left eye and deviation of angle of mouth to left(since 4years of age)
GRbs:85mg/dl
I/O:1300/5670ml
wt-59kgs
haematuria secondary to ? thrombocytopenia? traumatic foleys resolved.
A-Dilated cardiomyopathy secondary to ?CAD
with EF-28%
severe TR with PAH
diabetic
LMN facial palsy on left side since 4years of age.
P-1)propped up position
2)fluid restriction to <1lit /day
3)salt restriction <2g/day
4inj lasix titrated to dose of 10mg/hour.
5)inj dobutamine250mcg in 50ml ns @3.6ml/hr
6)tab ecosprin av 75/20mg /po/od
7)grbs 6th hourly premeal
8)syp cremaffin plus 10ml/po/hs
9) avoid strenuous activity.
10) tab hydralazine 12.5mg /po/bd
Soap notes:22/11/21
S-sob resolved.
scrotal swelling+ but decreased
orthopnea resolved.
dry cough- resolved
O-conscious,coherent
keloid scar present
pes cavus with varus(after consulting orthopaedics)
pedal edema+(b/l )
afebrile
BP-120/70mmhg
PR-93/min
CVS-JVP-normal
apex best seen and felt at left 6th ICS in annterior axillary line
parasternal heave in left side
S1,S2+,pansystolic murmur in pulmonary tricuspid areas
R.S-BAE+,end inspiratory coarse crepts in b/L LL (Lt>Rt)
P/A-distended,non tender
CNS-hmf intact
ptosis of left eye and deviation of angle of mouth to left(since 4years of age)
GRBS:106mg/dl
I/O:1000/2400ml
A-Dilated cardiomyopathy secondary to ?CAD
with EF-28%
severe TR with PAH
diabetic
LMN facial palsy on left side since 4years of age.
P-1)propped up position
2)fluid restriction to <1lit /day
3)salt restriction <2g/day
4)inj lasix 40mg/iv/bd
5)tab ecosprin av 75/20mg /po/od
6)grbs 6th hourly premeal
7)syp cremaffin plus 10ml/po/hs
8) avoid strenuous activity.
9) tab hydralazine 12.5mg /po/bd
Soap notes:23/11/21
S-sob resolved.
scrotal swelling+ but decreased
orthopnea resolved.
dry cough- resolved
O-conscious,coherent
keloid scar present
pes cavus with varus(after consulting orthopaedics)
pedal edema+(b/l )
afebrile
BP-120/80mmhg
PR-83/min
CVS-JVP-normal
apex best seen and felt at left 6th ICS in annterior axillary line
parasternal heave in left side
S1,S2+,pansystolic murmur in pulmonary tricuspid areas
R.S-BAE+,end inspiratory coarse crepts in b/L LL (Lt>Rt)
P/A-distended,non tender
CNS-hmf intact
ptosis of left eye and deviation of angle of mouth to left(since 4years of age)
GRBS:109mg/dl
I/O:1950/2900ml
A-Dilated cardiomyopathy secondary to ?CAD
with EF-28%
severe TR with PAH
diabetic
LMN facial palsy on left side since 4years of age.
P-1)propped up position
2)fluid restriction to <1lit /day
3)salt restriction <2g/day
4)inj lasix 40mg/iv/bd
5)tab ecosprin av 75/20mg /po/od
6)grbs 6th hourly premeal
7)syp cremaffin plus 10ml/po/hs
8) avoid strenuous activity.
9) tab hydralazine 12.5mg /po/bd
10) Syrup benadryl 10ml/po/bd
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