45 yr old female with DCMP with EF (56%), ANEMIA under evaluation and TYPE-2 DM
45 year old female patient came to casuality with c/o B/L left leg swelling since 1 and half year and right toe swelling and relieved treatment.
Since 1 month she developed B/L upper limb and face along with abdominal distention with decreased urine output since 10 days.
She started to experience dyspnea on exertion since 20 days which aggravated to dyspnea at rest since 3 days increased onlying down in supine position.
Also C/o non productive cough since 5 days.
Treatment history:
1. T. DYTOR 10 MG BD
2. T. MET XL 12.5 MG OD
3. T ATORVAS 40 MG OD
4. SYP ARISTOZYME 10 ML TID
5. T FRUSELAC 50 MG OD DAILY WITH T. METXL 3D 50 MG OD
Patient is diagnosed with DM 2 since 2 years and is on T. Glimi M2 BD
Personal history:
Passed stools 2 days back with reduced urine output.
General Examination:
Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Vitals at admission:
PR- 80 bpm
BP- 170/60 mmHg
RR- 22 cpm
SpO2- 98%
CVS: S1 S2 +,
RS: B/L inspiratory crepts in all lung fields
P/A: tender in right hypocho drive region.
Investigation:
Hb: 9.3
Tlc: 12300
Plt count: 1.97
BGT: A positive
Serology: negative
Diagnosis:
DCMP with EF: 56
Anemia under evaluation
Clinical images :
SOAP notes -
S- c/o dry cough
SOB reduced
Pedal edema reduced compared to yesterday
O - pt is conscious , coherent and cooperative
Pallor +
Temp -afebrile
Pr - 85 bpm
Bp - 190/90 mmHg
CVS - S1 S2 +
Rs - B/L inspiratory crepts noted in infr axillary and infra-scapular areas
CNS - nfnd
A - HEART FAILURE WITH PRESERVED EF -56%
Anemia under evaluation
P-
1.inj Lasix 40 mg IV /tid
2.inj actrapid s/c
3.tab met xl 25 mg po/od
4.tab amlong 10 mg po/od
5.tab atorvas 40 mg po/od
Planning to shift to amc
3/1/22
SOAP notes -
S- c/o dry cough
SOB reduced
Pedal edema present
Tingling sensation association with burning both feet
O - pt is conscious , coherent and cooperative
Pallor +
Temp -afebrile
Pr - 87 bpm
Bp - 170/90 mmHg
CVS - S1 S2 +
Rs - B/L inspiratory crepts noted in infr axillary and infra-scapular areas
CNS - nfnd
A - HEART FAILURE WITH PRESERVED EF -56%
Anemia under evaluation
P-
1.inj Lasix 40 mg IV /tid
2.inj actrapid s/c
3.tab met xl 25 mg po/od
4.tab amlong 10 mg po/od
5.tab atorvas 40 mg po/od
Planning to shift to Amc
4/1/22
SOAP notes -
S- c/o dry cough
SOB reduced
Pedal edema present
Tingling sensation association with burning both feet
O - pt is conscious , coherent and cooperative
Pallor +
Temp -afebrile
Pr - 87 bpm
Bp - 170/90 mmHg
CVS - S1 S2 +
Rs - B/L inspiratory crepts noted in infr axillary and infra-scapular areas
CNS - nfnd
A - HEART FAILURE WITH PRESERVED EF -56%
Anemia under evaluation
P-
1.inj Lasix 40 mg IV /tid
2.inj actrapid s/c
3.tab met xl 25 mg po/od
4.tab amlong 10 mg po/od
5.tab atorvas 40 mg po/od
SOAP notes -
S- c/o dry cough
SOB reduced
Pedal edema present
Tingling sensation association with burning both feet
O - pt is conscious , coherent and cooperative
Pallor +
Temp -afebrile
Pr - 87 bpm
Bp - 170/90 mmHg
CVS - S1 S2 +
Rs - B/L inspiratory crepts noted in infr axillary and infra-scapular areas
CNS - nfnd
A - HEART FAILURE WITH PRESERVED EF -56%
Anemia under evaluation
P-
1.inj Lasix 40 mg IV /tid
2.inj actrapid s/c
3.tab met xl 25 mg po/od
4.tab amlong 10 mg po/od
5.tab atorvas 40 mg po/od
Plan of treatment :
1. Head end elevation
2. Inj. LASIX40 mg IV TID
3. Tab. METXL 12.5 mg PO OD
4. TAB. ATORVAS 40 mg PO OD
5. FLUID RESTRICTION <1L/ DAY
6. SALT RESTRICTION. < 2 gm/ day
7. Daily weight monitoring
8. STRICT IO CHARTING
9. INJ. H.ACTRAPID INSULIN SC ACC. TO SLIDING SCALE 8 AM - 2PM- 8 PM
10.O 2 SUPPLEMENTATION TO MAINTAIN SPO2
11. MONITOR VITALS
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