44 YEAR OLD WITH SHORTNESS OF BREATH

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A 44 year old male patient it came to casualty with 
C/o shortness of breath (grade II) according to NYHA classification
Not associated with orthopnea/PND.
C/o B/L PEDAL EDEMA ( pitting type ) since 1 week 
C/o decreased URINE OUTPUT since 1 week
C/o FACIAL PUFFINESS since 1 week 
Pt was apparently asymptomatic 1 week back then developed fever associated with chills and rigor, was diagnosed with typhoid and was treated outside in a private hospital 
Pt also C/o loss of appetite, and 2 episodes of vomiting ( non bilious , non projectile ) not A/W nausea.
Pt is a K/C/O 
-CKD since 10 years on regular medication 
- DM since 4-5 years 
(on GLIMI M2 morning and GLIMI M1 night)
-HTN since 1 year - on Tab TELMA-AM
NO SIGNIFICANT FAMILY HISTORY

PERSONAL HISTORY

O/E- Pt is c/c/c obese , clubbing present
TEMP+98.4°F
BP-130/80MMHG
PR-89 BPM
RR- 20CPM
SPO2-98% @ RA
CVS-S1S2 HEARD NO MURMUR
RS-NVBS + NO CRYPTS
P/A-SOFT, NON TENDER
CNS-HMF INTACT
APEX BEAT- 6TH ICS LATERAL AND OUTWARD
JVP-RAISED , EPIGASTRIC PULSATIONS PRESENT 
WT-83 KG


PROVISIONAL DIAGNOSIS-
HEART FAILURE with PRESERVES EJECTION FRACTION with EF -55% WITH CKD SINCE 10 YEARS STAGE -IIIB with DM since 5 YEARS with HTN since 1 YEAR

TREATMENT-
SALT RESTRICTION < 2.4 GM/DAY
FLUID RESTRICTION< 1 LT/DAY
INJ LASIX 40MG /IV/BD ( IF BP>110MHG)
INJ PANTOP 40 MG /IV/OD
TAB. NODOSIS 550 MG /PO/OD
TAB. SHELCAL 500MG /PO/OD
TAB PCM 500MG /PO/SOS
INJ. PIPTAZ 2.25 G/IV/BD(DAY 1)
INJ. NEOMOL 100 ML /IV/SOS
MONITOR VITALS HOURLY
STRICT I/O CHARTING
INJ HAI PRE MEAL S/C 8AM-2PM-8PM
GRBS MONITORING














On 28th oct
 Serum creatinine -3.4 mg /dl 





ON 29 OCT
PLBS-109 mg/dl
FBS-97

On 29oct serum electrolytes


Usg reports- 29/10/21  and 3/11/21

Amylase - 46 IU/L

Lipase- 32 IU/L

Ecg done on 4-nov-2021





Serum electrolytes on 4/11/21



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