52 yr old male with DCMP with HFrEF , Type 2 DM , HTN , Hypothyroidism , Diabetic Neuropathy

A 52 yr old male from bhuvanagiri , carpenter by occupation came to casualty with c/o sob & decreased urine output from one day.

Patient was apparently asymptomatic 15 yrs back when he had an episode of giddiness, profuse sweating and altered sensorium at midnight for which he was taken to a hospital where he was diagnosed with type 2 DM and heart failure.

Angiogram was done and symptomatic treatment was given.

Patient was alright with those medications until last month when he developed anasarca , SOB and giddiness for which he visited a local hospital and from there he was referred to our hospital.

Here he was diagnosed with dilated cardiomyopathy secondary to ?cad , HFrEF , type 2 cardiorenal syndrome,dm+,htn + ,diabetic neuropathy and drug induced hypoglycemia.

Symptomatic treatment was given

He was alright with those medications until 3 days back when he developed sob & decreased urine output from one day.

Sob gradual in onset ,progressive,he wakes up 3 hrs after sleep with sob ass with palpitations,sweating.

Decreased urine output and b/l swelling of lower limbs (pitting type) with abdominal distension .

Patient had similar complaints in past 15 yrs back and angiogram was done (? pci was done )

K/c/o Type 2 DM since 15 yrs : Tab.Gliclazide 60 mg BD ---- Drug induced hypoglycaemia 20 days back ---- Tab.Gliclazide 30mg OD

K/c/o hypothyroidism on tab thyronorm 50 mcg

Not a k/c/o asthma,tb,epilesy 

Personal history: decreased appetite,non veg ,regular bowel movements ,decreased urine output

K/c/o alcoholic since 20 yrs 90 ml/day, stopped 6 months back

General examination 

Pedal oedema + 

No sign of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Temp :afebrile

PR:84/min

RR:20/min

Bp: 130/90mm/hg

Grbs :245 mg %

Systemic examination 

Cvs : No visible pulsations

         Apex beat palpable in 6th ICS 1 inch lateral to MCL

         s1s2 heard no murmurs 

Rs:B/L AE + , crepts present in B/L ISA , Inter Scapular & IAA

P/A : soft non tender ,no oraganomegaly

Cns: conscious,normal speech , cranial nerves intact ,motor and sensory system normal

INVESTIGATIONS

PROVISIONAL DIAGNOSIS :

DCMP with HFrEF , Type 2 DM , HTN , Hypothyroidism , Diabetic Neuropathy

TREATMENT :

1) salt restriction <2.4gm /day

2)fluid restriction <1lit /day

3)Inj LASIK 80mg / IV /BD

                                 1-0-1

4)Inj pantop 40mg /IV/OD   

                                  1-0-0

5)Neb Duolin  8th hourly

           Budecort 12th hourly

           Mucomist 12th hourly

6) Tab ecospirin -Av (75/20mg)/po   0-0-1

7)Tab cardivas 3.125mg /Po/ od   1-0-0

 8)Tab Thyronorm 50mcl/ po/od  1-0-0    (30mins before bf)

 9)Tab Gliclazide   30mg /po/BD   1-0-0

 10)strict diabetic diet

  11)Tab Pregaba- M 50mg/po/hs 0-0-1

 12) syp.Cremaffin plus 15ml/po/TID

 13)Isaphghula husk  sachet in 150ml water/po

 14)I/o Charting

 15)BP/ PR/spo2 charting 4th hourly

 16)GRBS charting 6th hourly

 17) Tab Aldactone 25mg/Po/od    1-0-0

 18)Tab Neurobion forte /Po/od      0-1-0 (2pm)

 19) Ramipril 5mg/po/od   1-0-0