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Here is a case i have seen:
A 56year old male patient cook by occupation,came to the hospital with the chief complaints of Facial puffiness with pedal edema and abdominal distension since 7 days .
SOB grade 3 since 3 days.
Dry cough since 2 days.
In 2015,He got diagnosed as diabetic ,during his regular checkup’s and was on medications since then.
In 2018 , one day ,while he was at work,he had a thorn prick near left great toe which he neglected ,after few days he developed a ulcer over the great toe,went to the local hospital and his toe was amputated to prevent further complications .
Patient was apparently asymptomatic 15 days back then he had thorn prick again at the site of the left amputated great toe which is not associated with pain ,fever ,pus discharge for which he got treated in the local hospital.patient then developed facial puffiness and pedal edema and then abdominal distension after 7 days.
Then patient developed SOB grade 3 (acc to NYHA,I.e SOB even after walking for 100 mts) after 3 days,Not associated with chest pain, palpitations,PND,orthopnoea.
H/O dry cough after 2 days .
Patient went to the same hospital ,and has been diagnosed as hypertensive ,so referred here for further management.
After admission ,patient complained of decreased urine output .
K/C/O DM type 2 since 5 years and on regular medication .(ie GLIMI M2).H/O numbness of plantar surfaces of both feet since 5 years .
K/C/O HTN since 7 days on tab.TELMA-H .
K/C/O alcoholic occasionally,since 30 years in family gatherings ( 90-180 ml whiskey).
No h/o fever,No GEcomplaints .
GENERAL EXAMINATION :
Pt is conscious,coherent,cooperative.
well built and nourished.
Transverse diameter of chest - 25cms
AP diameter of chest-20cms
Pallor present
No cyanosis
No clubbing
Bilateral pitting edema of feet present
Bilateral diabetic foot ulcers.
VITALS :
Temp -afebrile
PR -90bpm
BP-160/100mmhg.
RR-36cpm.
GRBS -84mg%
Systemic examination:
CVS -s1s2 heard,no murmurs.
RESP- grade 4 dyspnoea,wheeze present in mammary area ,vesicular breath sounds with bilateral end coarse inspiratory crepts in interscapular area.
P/A - shape of abdomen distended ,no tender ,No palpable mass ,bowel sounds present .
CNS- cranial nerves intact
sensory examination:
Fine touch -absent in bilateral feet till ankles.
crude touch -elicited.
Pain -Not elicited over plantar surface of both feet.
Temperature- elicited
vibration sense -elicited
INVESTIGATIONS:
DIAGNOSIS
HFpEF with k/c/o diabetic foot with non healing ulcer on left amputated great toe with denovo HTN with K/c/o diabetis Mellitus,with AKI.
TREATMENT :
Day1- (8/12/20).
Inj LASIX 40mg IV .
Tab TELMA H (40/12.5) OD.
Head end elevation.
Inj HAI according to sliding scale.
Neb with 1amp of Asthalin 8th hourly.
Syrup Cremaffin plus PO/HS
Syrup Ascoril 10ml PO/TID.
Inj 50meq NaHCO3 in 100 ml NS over 2hrs.
input :800ml
output- 600ml
Day 2-(9/12/20)
Inj LASIX 40mg IV TID.
Head end elevation.
Inj HAI acc to sliding scale .
Neb with 1amp ASTHALIN -8th hourly.
syp CREMAFFIN PLUS 15ml PO/HS
Syp ASCORIL 10ml PO/TID.
Tab NICARDIA 10mg SOS if systolic bp >150.
Tab CILICAR TC [40/10/125mg] OD.
Input-800ml
output-950ml.
Day3 ( 10/12/20)
Inj LASIX 40mg IV TID.
Tab CLINIDIPINE 10mg OD/PO.
Tab NICARDIA 10mg OD/PO if BP > 160.
Neb with 1amp ASTHALIN 8th hourly.
Syp CREMAFFIN PLUS 15ml PO/HS.
Head end elevation.
Syp ASCONIL 10ml PO/TID.
Input : 800ml
Output : 600 ml
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