51 yr old male with Heart failure with reduced ejection fraction Metabolic syndrome K/c/o DM ,HTN ,CVA ,Seizures

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. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 

CASE PRESENTATION

A 51 year old male patient who is a k/c/o DM since 7 yrs and HTN since 5 yrs have  H/O 1 episode of seizures(GCTS) in feb 2017 and got admitted  in our hospital  and was on tab. Phenytoin 100mg TID medication ecg taken at that time showed atrial  fibrillation  and EF was 54% 

Similar H/o 1 episodes of seizure after 1 year of 1st episode was given. Then in Aug 2019 he presented with c/o B/L pedal edema and generalised edema since 10 days which subsided with medication 2d echo showed EF of 30% 

Then now he presented to the opd with complaints of B/L pitting pedal edema from 5 to 6months,abdominal distension from 2 to 3 days,SOB from 3days.

Pedal edema is aggrevated from 2 to 3 days and decreased urine output from 2 days for which pt used T. Amiloride, Furosemide  40mg since 2 days

Sob since 3 days grade 2 , orthopnoea and PND are present.

Abdominal  distention  since 3 days

No H/O chestpain,palpitations,giddiness,sweating,yellowish discolouration of eyes, fever.

K/c/o DM from 7yrs on tab glimi M2 bd

K/c/o HTN from 5yrs on tab telma 40mg od 

K/c/o epilepsy from 5yrs on tab phenytoin 100mg bd

Occasional alcoholic from 10yrs

Tobacco chewing from 40yrs

Personal history - 

Appetite  normal

Mixed diet

Sleep adequate

Bowel regular

O/E 

Patient is C/C/C moderately built and nourished

Pallor present 

No icterus clubbing cyanosis lymphadenopathy

Pedal edema present upto knees , pitting type 

Vitals:

Patient is afebrile

BP 150/90mm hg

PR 96 bpm

RR 24cpm

Spo2 95 on RA

CVS :

Inspection-

   precordium no bulging

   No visible  pulsations,  no engorged  veins, no scars, no sinuses

Palpation- 

   no tenderness 

Apical impulse -

Auscultation - S1 S2 heard

RS : BLAE Present NVBS 

P/A : distended 

Abdominal girth - 106 cms

CNS : NAD

Investigations-

2d echo global hypokinesia 

EF 28%

Severe TR Severe PAH

Diastolic dysfunction 

ivc 2.4 non collapsing 

CXR - PA view

DIAGNOSIS :

Heart failure with reduced ejection fraction 

Metabolic syndrome

K/c/o DM ,HTN ,CVA ,Seizures

TREATMENT :

1. Fluid restriction < 1.5 lt/day and salt restriction <2.5gm/ day

2. Inj lasix 40 mg /IV/BD IF SBP>110 mg

3. TAB. MET XL 12.5 mg/PO/OD

5. TAB. PHENYTOIN  100 mg/PO/TID

6. ECOSPRIN IV (75/10mg) PO/OD

7. TAB. PAN 40 MG/PO/OD

8. INJ. HAI S.C according to sliding scale

9. DAILY WT MEASURING 

10. STRICT I/O CHARTING 

11. GRBS CHARTING  6TH HRLY 

12. TAB. PREGABLIN 75mg PO HS

13. INJ. OPTINEURON 1amp in 100ml NS/IV/OD

14. TAB. ENALAPRIL 2.5 mg OD