56 year male with shortness of breath ,palpitation

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A 56 yr old Male who is accountant was apparently asymptomatic 6 years back then he developed Shortness of breath, palpitation, Giddiness, buckling was present when he was going to home from his work.Then he came to our hospital , unknown medications were given,his symptoms were relieved.He developed  shortness of breath( Grade 2), pedal Edema till knee  which was dependent,giddiness and palpitations       1  1/2 year back for which he was brought to our hospital and was informed that he was having cardiac problem and referred to cardiologist where angiogram was done ,  informed them that surgery must be done ,he was diagnosed as diabetic  before surgery . one and half year ago CABG was done .        The patient developed  Shortness of breath (Grade-2), pedal oedema , giddiness, palpitations from past 6 days came to our hospital.No history of orthopnea,PND, cough, Syncopal attacks. 

 PAST HISTORY: known case of HTN from past  6 years using Metaprolol 12.5mg , D.M  on Metformin 500mg since 1 1/2 year .

PERSONAL HISTORY:Mixed diet with normal appetite and normal bowel and bladder habits

Chronic alcoholic and smoker 

No significant family history.

GENERAL EXAMINATION:

Patient is conscious , coherent, cooperative , moderately built and moderately nourished.

No pallor ,icterus, Cyanosis, clubbing, koilonychia, lymphadenopathy, pedal oedema is present . 

Vitals: Afebrile

           B.P: 100/70mmhg

           P.R: 72 bpm regular rhythm,

           R.R: 12cpm

           Spo2: 98 % At room air

           JVP : raised 

SYSTEMIC EXAMINATION:

Cvs:

Inspection: •precordium : Normal

                                        

                                        •No other pulsations

                                        •No dilated veins 

                                       •Central vertical scar is 

                                           Present

                                       •No sinuses

                   Palpation:• Apex beat : left 5 th ICS

                                    • No Thrills

                   Auscultation: s1,s2  present.

Respiratory system: B/L Air entry is present 

CNS: Higher mental functions: Normal 

          Cranial nerves intact 

          Sensory system intact 

                                                 Right.         Left 

          Motor system : Bulk : N.                 N 

                                  Power:  N.                 N

                                   Tone:   N.                 N

                                 Reflexes: Present     Present

          Cerebellar signs absent

Per abdomen: soft , non tender, no local rise of    

                         Temperature, No organomegaly 

INVESTIGATIONS: 

USG abdomen:  bilateral Grade 1RPD

                             Grade 2 fatty liver

                             IVC diameter: min: 6mm

                                                       Max: 17mm

2D echo:

Chest x ray:

PROVISIONAL DIAGNOSIS:Coronary artery disease( Triple vessel disease) with Heart failure with preserved ejection fraction with CABG done 1 1/2 year back ,K/c/o HTN since 6 years and DM since 2 years 

TREATMENT: 1) Fluid restriction <1.5 litres /day

                        2) salt restriction < 6 gm/ day

                        3)inj.Lasix 40 mg/IV /BD

                        4)Tab.Clopitab A (75/75 mg)OD

                        5)Tab.Atorvas /PO/OD/HS

                        6)Tab.Metfomin 500mg PO/OD

                        7) Tab. Metxyl 12.5mg PO/OD