72 y old with HFrEF 2° to CAD , AF WITH CVR

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A 72 y old male patient general physician by profession came to opd with the c/o palpitations and shortness of breath on exertion since 6 years
C/o insomnia since 10 years on alprazolam o.5 mg, 
C/o dryness of mouth on taking medication
No pedal edema, orthopnea, PND 
*2015 - ACUTE LV FAILURE  EF20% 
On cardivas , losartan  25mg , dabistar 110 mg
No h/o DM, SMOKING, ALCOHOL ,TB
K/C/O HTN since 6 yrs
NO SIGNIFICANT PERSONAL AND FAMILY HISTORY
O/E PT IS C/C/C MODERATELY BUILD AND NOURISHED
TEMP-98.1°F
PR-62BPM
RR-24 CPM
BP-140/90 MMHG
SPO2 99 AT ROOM AIR
SYSTEMATIC EXAMINATION
CVS-S1S2 HEARD
RS-BAE+ NVBS
ABDOMEN - SOFT ,NAD
CNS- NAD
PROVISIONAL DIAGNOSIS
HFrEF 2° TO CAD
AF with  CVR


TREATMENT
Tab. Pan 40 mg po/od 7am
Tab. Losar H 5p/12.5 mg po/od 8am
Tab. Dapaniflozin (oxra 10 mg) - po/od
Tab. Digoxin 0.25 mg po/oD
Tab. Cardivas CR Po/oD
Tab ALZOLAM O.5 po/oD





Discharge summary

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