HFrEF WITH EF 33% SECONDARY TO CAD (LAD TERRITORY S/P? MI) WITH K/C/O DM 2 WITH TYPE 1 VITILIGO VULGARIS, ALLERGIC CONTACT DERMATITIS, AZTEOTOTIC ECZEMA

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I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 64 year male patient, teacher by occupation came to the OPD with chief complaints of

1. B/L lower limb edema since 1 month

2. SOB since 1 month

3. Hyper pigmented patches over both shins and both hands 10 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 1 month back. Then he developed b/l lower limb swelling. It was insidious in onset, gradually progressed from feet to thighs and also involving scrotum. There is also a H/o of reduced physical activity.

There is SOB gradually progressing from grade 1 to grade 3. Not associated with any orthopnoea, palpitations. Aggravated on walking and relieved on taking rest.

From 10 days, the patient is having hyper pigmented patches over front of the leg and on both hands. Not associated with itching, gradually progressive. No aggravating and relieving factors.

PAST HISTORY

1 month ago, he was diagnosed with COVID 19 and was admitted for 10 days and was then discharged. In Feburary, he had sudden onset cough and SOB early in the morning at 4:00am. He was admitted to hospital for 4 days and was adviced angiogram. But the patient was not willing and discharged.

K/C/O Type 2 DM (25 years), on OHA Glimy-M1 BD

Not a K/C/O HTN, CAD, TB, asthma.

PERSONAL HISTORY

Diet - Mixed

Appatite - Reduced

Sleep - Adequate

Bowel and bladder - Normal

Addictions - None

FAMILY HISTORY

None significant 

GENERAL EXAMINATION

Pt is C/C/C

Moderately built and nourished

Afebrile

No pallor, icterus, cyanosis, lymphadenopathy,  clubbing

B/L lower limb pitting edema. Hyper pigmented patches seen on both shins and hands.

BP 130/70 mmHg

PR 84 bpm

RR 22 cpm

SpO2 98% in room air

GRBS 126mg/dl

 

CVS 

INSPECTION: 

1. Shape of Chest Symmetrical, moving equally with respiration

2. Trachea position central

3. No visible pulsations seen

No scars, sinuses or dilated veins seen in any part of  the thorax. 

No bony abnormalities seen (Spine)

PALPITATION: 

1- All inspector findings were confirmed.

2-Trachea is central.

3-Apex Beat confirmed to be in Lt 5th ICS 1cm lateral to MCL

PERCUSSION:

1. Rt border of heart corresponds to Rt sternal border

2. Lt border of heart corresponds to apex beat

3. Pulmonary areas  on percussion

AUSCULATION:

S1 and S2 heard

RS

BAE +, clear

P/A

Soft

Non-tender

Bowel sounds heard

CNS

No focal abnormalities detected

Diagnosis

HFrEF WITH EF 33% SECONDARY TO CAD (LAD TERRITORY S/P? MI) WITH K/C/O DM 2 WITH TYPE 1 VITILIGO VULGARIS WITH ALLERGIC CONTACT DERMATITS WITH AZTEOTOPIC ECZEMA

Chest X ray

Hb

CUE

2D ECHO

HbA1c

LFT

RFT

ECG

DVL REFERRAL

DAY 0

SOAP Notes

Subjective

Patient c/o swelling and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  85 bpm

BP - 130/70mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 17 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

HB 9.5

LFT

Albumin 2.8

Protein 4.6

A/G ratio 1.51

Total bil 0.88

Direct bil 0.19

SGOT 13

SGPT 10

RFT

Urea 5.9

Creatinine 1.8

Uric acid 1.4

FBS 79mg/dl

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. Protein powder 2 tbsp in milk bd

6. Fluid restriction till 1.5 litres/day

7. Salt restriction till 2 g/day

8. OHA to be continued

9. BP charting

10. I/O charting

11. GRBS monitoring 

Day 1

USG guided aspiration of ascitic fluid performed. 20 ml of fluid was removed. The removed fluid was sent for SAAG, ascitic fluid cell count, culture and sensitivity and gram staining.

SOAP Notes

Subjective

Patient c/o swelling and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  80 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 14 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

GRBS MONITORING 

22/08/21

8 AM 134mg

2 PM 111mg

8 PM 72 mg

23/08/21

8 AM 93 mg

Investigations

PLBS 94mg

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. Protein powder 2 tbsp in milk bd

6. Fluid restriction till 1.5 litres/day

7. Salt restriction till 2 g/day

8. OHA to be continued

9. BP charting

10. I/O charting

11. GRBS monitoring 

Day 2

SOAP Notes

Subjective

Patient c/o swelling and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  84 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 17 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

GRBS MONITORING 

23/08/21

8 AM  93mg/dl

2 PM 97mg/dl

8 PM 89mg/dl

24/08/21

8 AM 90 mg/dl

Investigations

Ascitic Fluid Analysis

Sugar 83mg/dl

Protein 2.2g/dl

Albumin 1.46g/dl

LDH 97 IU/l

SAAG 1.41

LFT

ALP 157 IU/L

Total Protein 5g/dl

Albumin 2.87g/dl

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. GLIMIPERIDE 0.5 gm/po/od

6. Protein powder 2 tbsp in milk bd

7. Fluid restriction till 1.5 litres/day

8. Salt restriction till 2 g/day

9. OHA to be continued

10. BP charting

11. I/O charting

12. GRBS monitoring 

Day 3

Tab Hydralazine was added to reduce the pedal edema.

SOAP Notes

Subjective

Patient c/o swelling (reduced) and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  89 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 14 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

GRBS MONITORING 

24/08/21

8 AM  90mg/dl

2 PM 131mg/dl

8 PM 89mg/dl

25/08/21

8 AM 122 mg/dl

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. GLIMIPERIDE 0.5 gm/po/od

6. HYDRALAZINE 25mg/po/od

7. Protein powder 2 tbsp in milk bd

8. Fluid restriction till 1.5 litres/day

9. Salt restriction till 2 g/day

10. OHA to be continued

11. BP charting

12. I/O charting

13. GRBS monitoring 

Day 4

SOAP Notes

Subjective

Patient c/o swelling (reduced) and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  87 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 16 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

GRBS MONITORING 

25/08/21

8 AM  122 mg/dl

2 PM 176 mg/dl

8 PM 163 mg/dl

26/08/21

8 AM 154 mg/dl

INVESTIGATIONS

24 hr urine volume 1700ml

24 hr urine protein 536.8 g

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. GLIMIPERIDE 0.5 gm/po/od

6. HYDRALAZINE 25mg/po/od

7. Protein powder 2 tbsp in milk bd

8. Fluid restriction till 1.5 litres/day

9. Salt restriction till 2 g/day

10. OHA to be continued

11. BP charting

12. I/O charting

13. GRBS monitoring 

Day 5

SOAP Notes

Subjective

Patient c/o swelling (reduced) and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  84 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 16 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. GLIMIPERIDE 0.5 gm/po/od

6. HYDRALAZINE 25mg/po/od

7. Protein powder 2 tbsp in milk bd

8. Fluid restriction till 1.5 litres/day

9. Salt restriction till 2 g/day

10. OHA to be continued

11. BP charting

12. I/O charting

13. GRBS monitoring 

Day 6

SOAP Notes

Subjective

Patient c/o swelling (reduced) and skin changes on limbs

Objective

Pallor -

Clubbing -

PR -  81 bpm

BP - 120/80mmhg

Afebrile 

Spo2 - at 99% on RA

RR - 18 cpm

CVS - S1 S2 +

RS - BAE +

CNS - No FAD

Per Abdomen - Soft, non-tender, Bowel sounds +

Assessment

HFrEF (EF 33%) secondary to CAD k/c/o type 2 diabetes with type 1 Vitiligo vulgaris with allergic contact dermatits with azteotopic eczema

Plan of treatment

1. Head end elevation

2. Tab DYTOR PLUS 10mg/po/bd

3. MOMATE cream for l/a od

4. MOISTUREX SOFT cream for l/a

5. GLIMIPERIDE 0.5 gm/po/od

6. HYDRALAZINE 25mg/po/od

7. Protein powder 2 tbsp in milk bd

8. Fluid restriction till 1.5 litres/day

9. Salt restriction till 2 g/day

10. OHA to be continued

11. BP charting

12. I/O charting

13. GRBS monitoring 

Discharge Summary