Dilated cardiomyopathy case
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A 50 year old male patient presented to OPD with chief complaints of pedal edema since 2 months, decreased urine output since 15 days,abdominal distension since 15 days,SOB Since 15 days.
History of present illness:-
Patient was apparently asymptomatic 2 months ago then he developed pedal edema started in foot and spread to knees and the edema increased since 15 days,break in the stream of urination,SOB Grade 3.
Known case of diabetes since 5 years and on oral hypoglycemic drugs.
Not a known case of HTN.
History of deviation of mouth to left since childhood.
Personal history:-
Diet:-Mixed
Bowel and bladder:-Normal
Micturition:-normal
Habits:-alcoholic:-1-2times/week 90ml since 20 years
Smoker:-1 pack/day since 20yrs.
Family history:-
No relevant history in family.
PHYSICAL EXAMINATION
General examination
Patient is conscious coherent co operative.
No pallor
No cyanosis
No clubbing
No lymphadenopathy
Edema of foot present
Vitals:-
Temperature:-afebrile
Pulse rate:-100/min
Respiratory rate:-22 cycles/min
Blood pressure:-110/70mmof Hg
SpO2:-98%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP -normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
Abdomen:-
Obese
No tenderness
No palpable mass
Free fluid present
No bruits
Bowel sounds present
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
INVESTIGATIONS:-
Hemogram:-
LFT:-
ECG:-
2D echo cardiography
Clinical images:-
Diagnosis:-
Dilated cardiomyopathy secondary to CAD.
Treatment:-
Injection Lasix 40mg iv bd
Tab Ecospirin po OD
Salt restriction<2g/day
Fluid restriction <1.5L/day.
GRBS 6TH hourly.
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