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.