65 yrs old female already on treatment of htn earlier 7 day back no was 180/100 sob padel edema generalised swelling chest clear ecg twnl blood sugar was 304 random xray was normal..started OHA with olmesar-ch20 . Now patient came yesterday with normal bp .sugar random 215 ..and tft report came this attached. still sob persist but with some improvement. ..OHA ESTAMET 50/500 started..thyroxine 50 stated....what else..mx invx ..tx??

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Dear Kamal, This is a case of 1) T2DM Uncontrolled 2) HTN Uncontrolled 3) Hypothyroidism Uncontrolled 4) SOB 5) Anasarca Investigations. In such cases we must R/O CCF first. 1) FPG 2) 2hr PG 3) HbA1c 4) RFT 5) Serum Electrolytes 6) Fasting Lipid profile 7) CBP 8) CUE 9) ECG 10) 2D Echo 11) Micral The present medications are 1) Olmesartan 20 mg 2) Chlorthalidone 12.5 mg 3) Sitagliptin 50 mg 4) Metformin 500 mg 5) Thyroxine 50 mcg. She must consult a Cardiologist first to R/O CCF and ASCVD. Silent MI is very common in DM. We should never expect pain to be a symptom in ASCVD, because of Autonomic Neuropathy. Management. Continue the present medications. Is Istamet 50/500 OD or BD ??? This should be preferably BD. She requires a loop Diuretics like Tab Torsemide 10 mg. Add Vit D supplements Add Tab Methylcobalamine 1500 mcg once a day. Rest of the treatment by Cardiologist depending on the Diagnosis. Keep monitoring DM HTN TSH. Add Statin ASA Based on the 10 yr CVD risk profile if more than 10% or In between 5% to 10% too to prevent further damage and to protect Against ASCVD, CVA. Thanks again dear Kamal for giving me an opportunity to answer your question. Please mention Height Weight BMI. Because these anthropometric measurements are mandatory in DM, HTN.

To add to your valuable answer sir, this pt would benefit greatly from a SGLT2i too...
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do 2 D echo. Sob is probably dystolic dysfunction due to age and hypertension. add some additional diuretics for some time. look for anemia which may be coexist more so because of hypothyroidism.

also do cbc LFT kft fasting sugar lipid profile post meal sugar HbA1C and urine microalbumin
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Hypothyroidism, advised elthroxin, continue antihypertensive & hypoglycemics.

do the following investigations 1.hba1c kft uacr lipids lft USG hbs & kidneys retinoscopy to r/o for add statins to the treatment l will add thimine also. u can increase the dose of diuretic

increase the dose of metformin after checking kft
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Go for 2 D echo Add dytor plus Methycobal Solo D3 weekly

Diabetes is still out of control. Pt is hypothyroid you have started thyroxine correctly. Bring both condition under control and pt will be OK.

I would suggest that oha be stopped and start with insulin keeping in mind there's a target organ damage

The DM and Hypothyroidism coexist. Generalised swelling due to hypothyroidism. DM still uncontrolled.

where from the pt is

get her CBC, FLP ,S CR. B.UREA DONE START L-THYROXIN@1.6

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