A 45 year old female with DCMP

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

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 days45 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.

Patient is diagnosed with DM 2 since 2 years and is on T. Glimi M2 BD 

Personal history:

Diet -mixed,appetite- decreased,bowel and bladder- irregular (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:

On the day of admission-

Clinical images of 6th January 

SEROLOGY-

Negative for anti HCV Antibodies, HbSAg,HIV 1&2

INVESTIGATIONS-

RBS -193mg/dl

Blood urea-65mg/dl

Serum creatinine-1.8mg/dl

On 02-01-2022                                                

RBS-142mg/dl

Serum creatinine-2.1mg/dl

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 

3-01-2022

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

 

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 

5/01/2021

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