2/11/2020

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A 44 year old male presented to the opd with chief complaints of shortness of breath.

C/O Pedal edema since 1 week

C/o decreased Urine patient since 1 week

C/o  Facial Puffiness since 1 week

C/o loss of appetite,

and 2 episodes of vomitings

Patient was apparently asymptomatic 5 days ago then he developed high grade fever associated with chills and rigors was diagnosed with typhoid and he took medication for that.

No h/o loose stools 

No h/o cough

No h/o burning micturition 

No h/o hematuria,melena, bleeding gums, hematemesis and no other bleeding manifestations 

Known Case Of 

CKD since 10 years with regular medication.

DM since 4-5 years 

HTN since 1 year

He has normal appetite,takes mixed diet, regular bowel and bladder movements,no addictions.

On examination patient is conscious, coherent and cooperative 

Obesed.

Pallor seen

Clubbing is seen

Vitals: 

Temp-98.4 degrees F 

PR-89 bpm 

RR-20 cpm 

BP-130/80 mm Hg 

Spo2:98% at room air 

RS: Bilateral air entry+;clear 

P/A:soft,non tender 

CVS:S1S2+

CNS: HMF Intact.

APEX BEAT- 6TH ICS LATERAL AND OUTWARD

JVP-RAISED , EPIGASTRIC PULSATIONS PRESENT 

WT-83 KG

Provisional Diagnosis:

Heart failure with Preserves Ejection Fraction with EF - 45% with CKD since 10 years with DM since 5 years with HTN since 1 year.

INVESTIGATIONS: 

Haemogram:

CBP :

LFT :

Ultrasound Report :

Color Doppler 20 Echo:

Radiometer ABL800 Basic :

Arterial sample type 

Blood Sugar : 105 mg/dl 

Serum Creatinine: 3.4 mg/dl

Blood Urea : 102 mg/dl

Serum Electrolytes:

Na : 122 mEq/L

K : 4.7 mEq/L

Cl-94 mEq/L

Peripheral Smear :

RBC : Normocytic,Normochromic

WBC : Leucocytosis

Platelet : Thrombocytosis.

Treatment:

SALT RESTRICTION < 2.4 GM/DAY

FLUID RESTRICTION< 1 LT/DAY

INJ LASIX 40MG /IV/BD ( IF BP>110MHG)

INJ PANTOP 40 MG /IV/OD

TAB. NODOSIS 550 MG /PO/OD

TAB. SHELCAL 500MG /PO/OD

TAB PCM 500MG /PO/SOS

INJ. PIPTAZ 2.25 G/IV/BD(DAY 1)

INJ. NEOMOL 100 ML /IV/SOS

MONITOR VITALS HOURLY

STRICT I/O CHARTING

INJ HAI PRE MEAL S/C 8AM-2PM-8PM

GRBS MONITORING