70yr old male with Heart failure with mid range EF with Dilated cardiomyopathy

70 yr old male who is a farmer  from Amanabolu .Complaints of shortness of breath since 3 months intially Grade 2 progressed to Grade 3 associated with orthopnea +,giddiness+ immediately on standing since 10 days ,pedal edema + since 2 months
Complaints of pain in the right shoulder elbow since One year( hit with stick by son )
No h/o chest pain,palpitations, decreased urine output 
Patient was apparently asymptomatic 3 months back then developed shortness of breath which was initially grade 2 and progressed to grade 3 a/w orthopnea and patient started developing pedal oedema since 2 months, grade 3 which was gradually progressing and relieved on  medications 
Past history:
Not a k/c/o DM,HTN,TB,Asthma, Epilepsy. 
K/c/o heart failure. 
Personal history:
Diet intake normal,appetite normal 
Bowel and bladder movements regular 
No known allergies
Occasionally drinks toddy.
General examination:
Patient is conscious ,coherent, cooperative,.
Temp:febrile
Bp:90/70 mmhg
PR: 74bpm
RR: 16 cycles per min
Sp02 :97%
CVS:
S1,S2 heard
RS: BLAE +
P/A :soft,non tender
CNS : NAD
Provisional Diagnosis: Heart failure with mid range ejection fraction with dilated cardiomyopathy with rotatory cuff tendiniti sencondary OA Right Elbow ,OA Right knee with synovitis.
On the day of admission 
treatment :1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
DAY-1 :
                   1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
                   7.Tab zincovit po/OD
                   
DAY-2 :      1.inj lasix 40 mg iv/BD
                   2.inj pan 40 mg iv/OD
                   3.optineuron 1 amp IM/OD
                   4.Fluid and salt restriction strictly maintained 
                   5.Tab ramipril 5 mg PO/OD
                   6.TAB.Ecosprin-av 75/20 po/OD
                   7.Tab zincovit po/OD
                   8.Tab.clopidogrel 75 mg po/OD
                   9.Tab.Sorbitrate 5 mg po/OD
patient c/o pain over right shooulder on right elbow. H/o trauma 1 yr ago over right arm
O/L/E-
Right sholuder-Diffused tenderness,Rom-painful and Restricted 
Right Elbow--Diffused tenderness,Rom-painful and Restricted
Investigation -X ray Rt shoulder Ap ,lateral-sclerosis at greater tuberosity
x- ray Rt elbow AP , Lateral -osteophyte formation both over Radius Ulna articular margins
2D ECHO
USG ABDOMEN

                


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