HEART FAILURE WITH PRESERVED EJECTION FRACTION (54%) LUMBAR SPONDYLOSIS TYPE 2 DM HYPERTENSION

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60YR OLD FEMALE PATIENT CAME WITH C/O LOW BACK ACHE SINCE 8 MONTHS

C/O B/L LOWER LIMB SWELLING SINCE 20 DAYS

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN SHE DEVELOPED LOW BACK ACHE OF INSIDIOUS ONSET, GRADUALLY PROGRESSIVE, RADIATING TO BOTH LOWER LIMBS, DECREASED RANGE OF MOTION, A/W TINGLING SENSATION.

H/O B/L PEDAL EDEMA EXTENDING UPTO KNEES SINCE 20 DAYS RELIEVING ON TAKING REST.

H/O SOB GRADE I MMRC

NO H/O CHEST PAIN, PALPITATIONS.

NO H/O PND, ORTHOPNEA, DECREASED URINE OUTPUT

NO H/O COUGH, COLD, FEVER

PAST HISTORY:

K/C/O DM TYPE II SINCE 1 YEAR ,ON GLIMIPERIDE 1MG PO/OD

NOT  A K/C/O CAD, CVA, SEIZURES,  TB, ASTHMA, THYROID DISORDERS

H/O JAW TUMOR

S/P- LEFT FIBULAR BONE GRAFT TO MANDIBLE

PERSONAL HISTORY:

DIET- MIXED

APPETITE- NORMAL

BOWEL AND BLADDER MOVEMENTS- REGULAR

SLEEP- ADEQUATE

ADDICTIONS- NONE

MENSTRUAL HISTORY- ATTAINED MENOPAUSE 15 YRS BACK

GENERAL EXAMINATION:

PT IS C/C/C

AFEBRILE

BP-140/80 MMHG

PR- 86BPM

RR-22CPM

SP02- 96% AT RA

GRBS- 133 MG%

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD

RS BAE +

GIT SOFT NT

CNS NFND

ORTHO REFERRAL DONE

ADVISE 

LS BRACE

TAB SHELCAL PO/OD

TAB DOLO 650 MG PO/BD


INVESTIGATION:

HEMOGRAM:

HB- 12.0 G/DL

TLC- 11000CELLS/CUMM

N/L/M/E/B- 45/45/05/05/00

PCV-36.2 VOL%

MCV-82.0 FL

PLATELET-3.32 LAKS/CUMM

SMEAR-NORMOCYTIC NORMOCHROMIC

CUE:

ALBUMIN- TRACE

 SUGARS-NIL

PUS CELLS- 2-4

EPITHELIAL CELLS- 2-3

TROPONIN I- 2.5 PG/ML

FBS- 105 MG/DL

SEROLOGY- NEGATIVE

RBS-142 MG/DL

RFT-

UREA- 25MG/DL

CREATININE-0.6 MG/DL

URIC ACID- 2.2 MG/DL

CA-10.1 MG/DL

P-3.4 MEQ/DL

NA- 137 MEQ/DL

K- 4.1 MEQ/DL

CL- 98 MEQ/DL

LFT:

TB- 0.50 MG/DL

DB-0.19 MG/DL

AST-18 IU/L

ALT-17IU/L

ALP-188IU/L

TP-7.2 G/DL

ALB-4.33 G/DL

A/G- 1.51


DIAGNOSIS:

HEART FAILURE WITH PRESERVED EJECTION FRACTION (54%)

LUMBAR SPONDYLOSIS

TYPE 2 DM

HYPERTENSION


TREATMENT:

1. T.LASIX 40 MG PO/OD

2. T. TELMA 40 MG PO/OD

3. T. GLIMIPERIDE 1 MG PO/OD

4.T. DAPAGLIFLOZINE 10 MG PO/OD

5. T. SHELCAL 500 MG PO/OD

6. T. ZERODOL-SP PO/OD

7. T. PREGABA-M PO/OD

8. T.ECOSPIRIN AV 75/20 PO HS


ADVICE AT DISCHARGE:

1. T.LASIX 40 MG PO/OD

2. T. TELMA 40 MG PO/OD

3. T. GLIMIPERIDE 1 MG PO/OD

4.T. DAPAGLIFLOZINE 10 MG PO/OD

5. T. SHELCAL 500 MG PO/OD

6. T. ZERODOL-SP PO/OD

7. T. PREGABA-M PO/OD

8. T.ECOSPIRIN AV 75/20 PO HS

9. L S BRACE

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