Case 29 78 male with pain abdomen since 4 days

Doa 19/1/24

Dod 22/1/24

Diagnosis

CONGESTIVE HEART FAILURE (EF - 35%)

K/C/O DM II SINCE 7 YEARS

K/C/O CKD SINCE 4 YEARS

K/C/O HTN SINCE 4 YEARS

S/P BELOW KNEE AMPUTATION 4 YEARS AGO

Case History and Clinical Findings

55 YR OLD MALE CAME TO GM OPD WITH C/O PAIN ABDOMEN SINCE 4 DAYS

PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS

DIAGNOSED WITH

CONGESTIVE HEART FAILURE (EF - 35%)

. MEDICALLY MANAGED WITH

INJ LASIX 40 MG IV TID, IAB CARDIVAS 3.125 MG PO BD

TAB MET XL 25 MG PO OD, T DAPAGLIFLOSIN 10 MG PO OD, TAB DYTOR PLUS 10/25 PO OD

K/C/O DM II SINCE 7 YEARS

K/C/O CKD SINCE 4 YEARS

K/C/O HTN SINCE 4 YEARS

S/P BELOW KNEE AMPUTATION 4 YEARS AGO

GENERAL EXAMINATION:

PATIENT IS C/C/C

PALLOR PRESENTNO SIGNS OF ICTERUS, CYANOSIS, CLUBBING, GENERALISED

LYMPHADENOPATHY

VITALSTEMP 98.2 FBP - 110/60PR- 88 BPMRR -16 CPMSPO2 - 98 % ON RA

GRBS 197 MG/DLSYSTEMIC EXAMINATIONCVS - S1 S2 HEARDRS - BAE +CNS - NO FNDP/A -

DIFFUSE ABDOMINAL TENDERNESS WITH RIGIDITY

USG

2D ECHO

MILD MR TR WITH PAH, MODERATE AR

RWMA +, LCX, RCA HYPOKINESIA

NO AS/MS

MILD LV DYSFUNCTION

DIASTOLIC DYSFUNCTION +

NO PE

Investigation

NameValueRangeNameValueRangeRFT 19-01-2024 05:51:PMUREA53 mg/dl50-17

mg/dlCREATININE1.9 mg/dl1.3-0.8 mg/dlURIC ACID4.9 mg/dl7.2-3.5 mg/dlCALCIUM7.0 mg/dl10.2-

8.6 mg/dlPHOSPHOROUS3.9 mg/dl4.5-2.5 mg/dlSODIUM137 mEq/L145-136 mEq/LPOTASSIUM5.0

mEq/L5.1-3.5 mEq/LCHLORIDE101 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 19-01-2024

05:51:PMTotal Bilurubin0.55 mg/dl1-0 mg/dlDirect Bilurubin0.19 mg/dl0.2-0.0 mg/dlSGOT(AST)13

IU/L35-0 IU/LSGPT(ALT)10 IU/L45-0 IU/LALKALINE PHOSPHATE181 IU/L119-56 IU/LTOTAL

PROTEINS6.1 gm/dl8.3-6.4 gm/dlALBUMIN3.98 gm/dl4.6-3.2 gm/dlA/G RATIO1.88HBsAg-RAPID19-

01-2024 05:51:PMNegative Anti HCV Antibodies - RAPID19-01-2024 05:51:PMNon Reactive

COMPLETE URINE EXAMINATION (CUE) 19-01-2024 05:51:PMCOLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGAR+BILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilPOST LUNCH

BLOOD SUGAR19-01-2024 11:51:PM196 mg/dl140-0 mg/dl

Treatment Given(Enter only Generic Name)

INJ LASIX 40 MG IV TID,

TAB CARDIVAS 3.125 MG PO BD

TAB MET XL 25 MG PO OD,

T DAPAGLIFLOSIN 10 MG PO OD,

TAB DYTOR PLUS 10/25 PO OD

Advice at Discharge

INJ HUMAN ACT RAPID INSULIN

10 U ------ 10 U ------- 8 U

T CARDIVAS 3.125 MG PO BD

T MET XL 25 MG PO OD

T DAPAGLIFLOZIN 10 MG PO OD

Follow up in june 2024

FBS 134 plbs 185 hba1c 6.0

follow up in january 2025

Fbs 98 plbs 127 hba1c 5.9