I'm attached to the cardiology ward. I need to present this case in great detail, as my preceptor is very strict, and I need to have a very good understanding of the case and all guideline-based recommendations, such as CPG Malaysia, and so on.Ill need a very good understanding of the disease, medication, why what all the 7W questions.Pls discuss all general available treatment as well for this case so i know what other choices of medicines are also available and the suitability Usually, the flow of the presentation goes like: Flow of presentation: 1. Patient, age, gender 2. ⁠what is the chief complaint 3. ⁠what is the diagnosis 4. ⁠on day 1 admitted, wht problem then give what medication, indication for what, then is it appropriate to give the med for this problem, any more better option? (No pci then skip nxt day- same flow summary - until the last day) 5. ⁠next day, some symptoms resolve, dr stop certain medication due to …. Then some other problem arise and dr prescribe ….. the indication for the medication is for …… is it appropriate….. 6. ⁠overall no PCI in this case / u found some pci and need some clarification….. 7. ⁠thank you but rather than solely mentioning if the medications are appropriate or not, it would be better to state the indications. For eg, this pt was started on Tab pantoprazole 40mg BD for (indication) from (duration). Then if anything was found inappropriate/incorrect, it can be mentioned as a PCI & then explain accordingly. Your flow is correct. Just follow the CP2 sections. Ill attach the CP2 form. But some preceptor wants it to b like a story telling like : 1. Patient, age, gender 2. ⁠what is the chief complaint 3. ⁠tell the diagnosis , then the medicines instead of the medicine first then the indication. And carry on with the flow So i want u to generate 2 types of complete script for my presentation Patient name: NS Age: 64 years Sex: Female Underlying: DM HPT CKD stage 3A HFrEF for investigation to rule of ischemic cause ECHO done on 4/2/26: LVEF 32%, RWMA global hypokinesia Plan for NPS viability study KIV COROS (Pls explain more about this) +- PCI Last admission in April 2026 for Decomp HFrEF TRO abdominal malignancy -Ca 125: 257 (whats this) - other tumour marker not raised -S/B gynae: limited TAS finding to get USG abdomen USG abdomen 27/4/26: Impression: Fatty liver with hepatomegaly B/L renal parenchymal disease Right pleural effusion with mild ascites No abdominal mass / collection Patient old meds: T.Lasix 40 mg OD T. Bisoprolol 2.5 mg OD T. Atorvastatin 40 mg OD T. glyprin 1/1 OD S/C mixtard 18/20 unit T. pantoprazole 40 mg OD Panel Parameter (Normal Range) 15/4/26 14/6/26 15/6/26 16/6/26 17/6/26 FBC TWBC (4-11 times 10^9/L) — 8.25 — — — Hb ($11.5-16.5 \text{ g/100mL}$) — 10.6 — — — Platelet ($150-400 \times 10^9/\text{L}$) — 294 — — — BUSE / Renal Urea ($1.7-8.3 \text{ mmol/L}$) 9.5 12.9 13.5 15.1 — $\text{Na}^+$ ($135-145 \text{ mmol/L}$) — 137 136 143 — $\text{K}^+$ ($3.5-5.0 \text{ mmol/L}$) — 4.6 4.0 3.6 — $\text{Cl}^-$ ($96-106 \text{ mmol/L}$) — 97 96 99 — SCr ($64-122 \ \mu\text{mol/L}$) 149 136 136 151 — $\text{Ca}^{2+}$ ($2.1-2.6 \text{ mmol/L}$) — 2.21 — — — $\text{Mg}^{2+}$ ($0.7-1.3 \text{ mmol/L}$) — 0.99 — — — $\text{PO}_4^{3-}$ ($0.8-1.45 \text{ mmol/L}$) — 1.27 — — — eGFR — 35 — — — LFT Albumin ($35-50 \text{ g/L}$) — 26 — — — T.Bilirubin ($<20 \ \mu\text{mol/L}$) — 54.3 — — — T.Protein ($66-87 \text{ g/L}$) — 71 — — — ALP ($53-141 \text{ u/L}$) — 351 — — — ALT ($<32 \text{ u/L}$) — 7 — — — CE AST ($<37 \text{ u/L}$) — 37 — — — Others Urine PCR — 1.17 g/mmol — — — Date 14/6 15/6 16/6 17/6 Input 350 650 600 450 Ouput 950 1400 500 300 Balance -600 -750 +100 +150 14/6 Present to ED on 14/6 with Worsening failure symptoms Orthopnea Bilateral pitting edema Abdominal distension 14/6 10.50 am Currently: Less SOB Orthopnea Unable to lie flat On examination: alert BP: 138/83 mmHg PR: 94 SPO2: 98% DXT: 12.3 Lungs: Bilateral creps till M2 P/A: Thick abdomen, distended bilateral sacral + Breast edema CXR: Cardiomegaly with bilateral pleural effusion ECG: SR, Poor R wave progression Impression: Acute decompensated HF with underlying HFrEF Plan: Start IV Lasix 80 mg TDS IV Human albumin 20% 100 cc x 3/7 I/O Charting ROF 500 cc/day + low salt diet Daily RP monitoring (what is RP?) Start T. Dapagliflozin 10 mg OD (own med) T. Bisoprolol 5 mg OD Continue other own medicines Start T Valsartan 40 mg OD DXT QID S/C Mixtard 10/16 U BD S//C Clexane 40 mg OD (DVT prophylaxis) KIV MRA 15/6/26 8.35 am Currently: Under Room Air , less SOB, edema reducing On examination: alert, conscious BP: 118/76 mmHg PR: 68 Temp: 37 SPO2: 99% under room air I/O: 350/950=-600 Lungs: under a/e bilateral LL with crepitation (reducing compared to yesterday) Abdominal edema: reducing Bilateral pedal edema up to shin Impression: Acute decompensated HF with underlying HFrEF Plan: Continue IV Lasix 80 mg TDS with human albumin Strict I/O Charting ROF 500 cc/day + low salt diet Add T. Spironolactone 12.5 mg OD Take RP today To get new NPS date / CMRI date upon discharge DXT QID For COROS once able to lie flat 16/6 9.20 am Issue: Acute decompensated HF with underlying HFrEF Uncontrolled DM CKD Stage 3A Currently: Less SOB, orthopnea, generalised edema (reducing) On examination: not tachypneic BP: 140/72 mmHg PR: 61 Temp: 37 SPO2: 100% I/O: 650/1400/-750 Lungs: Bilateral LL crepts with under a/e Bilateral pedal edema up to shin with wrinkle signs (improving) Plan: Increase T. Spironolactone 25 mg OD Reduce IV Lasix 60 mg TDS + IV human albumin (continue 3/7) Strict I/O charting For COROS ULR? Off load / able to lie flat (aim thursday) Take RP today Change to basal bolus S/C actrapid 6 U TDS and S/C Inuslatard 18 U ON DXT QID # If BP permiasable and AKI improved KIV increase T. Valsartan 17/6 10 am Under room air, no more SOB BP unsupported ( meaning pls) Still have orthopnea No pedal edema Plan: T. Lasix 40 mg BD T. Spironolactone 12.5 mg BD T. Valsartan 40 mg BD For COROS if able to lie flat 18/6 10 am Issue: Acute decompensated HF with underlying HFrEF Currently: Under room air Unable to lie flat Orthopnea Still edematous O/E: alert, conscious , not tachypenic BP: 103/57 PR: 65 SPO2: 98% under room air Lungs: under a/e over bilateral LL + generalised edema (Improving) U/O: 450/300/+150 Plan: Continue off load For COROS once able to lie flat ROF 500 cc/day plus low salt diet IV lasix 40 mg TDS Medications given according to the mediation chart is: IV lasix 80 mg TDS given only at 8 am. 4 pm and 12 am not given T. empagliflozin 25 mg OD given everyday at 8 am from 14/6 till now T. spironolactone 12.5 mg OD given only at 16/6 8 am, then stopped. T. spironolactone 25 mg OD given on17/6 8 am and stopped S/C actrapid 6 units TDS S/C Insulatard 18 unit ON IV Lasix 60 mg tds given staRTING from 16/612 pm and 17/6 6 am and stopped T. spironolactone 12.5 mg BD given starting from 17/6 6 pm and continue on 18/6 8 am T. atorvastatin 40 mg ON from 14/6 till now T. glyprin 1/1 OD from 14/6 till now S/C clexane 40 mg OD fron 14/6 till now T.pantoprazole 40 mg OD from 14/6 till now IV lasix 80 mg TDS given from 14/6 till 16/6 and stopped IV human albumin 20% 100 cc OD x 3/7 given from 14/6 till 16/6 and stopped T. Bisoprolol 5 mg OD from 14/6 till now T. valsartan 40 mg OD from 14/6 till now …………………………………………………………………………………………………….. HOSPITAL SULTANAH BAHIYAH (Un-Official Report) Order ID RDIP00001240682 Order Category Radiology Order Type Ultrasonography Priority Urgent Patient Norsiah Binti Darus ,Female/64Y,ID:AS00908242 Encounter ID 16156001 Order Date Time 27/04/2026 08:36 Order Status Resulted - Complete Ordering Location Nursing Unit/CRW Ordering Practitioner Tan Jie Nee, DR Ordering Facility HOSPITAL SULTANAH BAHIYAH HOSPITAL SULTANAH Performing Facility BAHIYAH Order Format s/t Dr. Ong, granted U/S abdomen in patient USG abdomen TRO causes of abdominal distention + USG KUB TRO obstructive uropathy Underlying 1) DM - HbA1C July 2021: 8.2% - Under KK Simpang Kuala - on S/C Insulin & OHA 2) HPT 3) ?CKD stage 3A 4) IHD with HFrEF H/o admission in July 2021 for NSTEMI ECHO done on 4/2/26: ALL CHAMBER NORMAL SIZE MILD MR PR FLOW WITH PAEDP 12mmHg MILD TR WITH PASP 28mmHg NO AR/AS RWMA PRESENT-GLOBAL HYPOKINESIA LVEF 32% BY SIMPSON NO LV CLOT NO PERICARDIAL EFFUSION T Clinical Atorvastatin 40mg ON T Cardirpin 100mg OD T Bisoprolol 5mg OD S/C Mixtard 18/20 unit BD T Pantoprazole Comments 40mg OD T Spironolactone 25mg OM T Valsartan 40mg OD T Dapiga 10mg OD (self purchase) ============================= Admitted for 1. Symptomatic ascitis with under HFrEF 2. Congestive hepatopathy 3. AKI on CKD Tro obstructive uropathy breathlessness for x2/52 - worsening for x2/7 ABdominal distension x2/52 - gradually increasing LL swelling x2/52 Orthopnea + PND x2/7 PA: Soft non tender, generalised swelling, no mass palpable bedside scan done by Dr Tan CY (Cardio fellow): no ascitic fluid seen no tapping window Ur 11.3 -> 21:Cr 147 -> 278 AST 27 T. bili 21 -> 14 ALP 288-> 286 Reporting Practitioner : DRKANMANI2 Resulting Time : 30/04/2026 09:10 Event Date Time:30/04/2026 09:10 US Abdomen Abdomen performed on 30.04.2026. D1trasound ** Suboptimal study due to thick abdomen Findings: Liver appears homogenously increase in echogenicity with regular margin. No focal lesion. It measure s 16.5cm. No intrahepatic or extrahepatic ducts dilatation. Portal veins is patent with normal doppler flow: Gall bladder is well distended with thin wall. No gall bladder stones or sludge. No pericholecystic fluid collection. Visualised pancreas is normal. Spleen is normal with no focal lesion. It measures. 7.6cm. Both kiceys are normal in size and shape. However, both increase in echogenicity. Right kidney bipolar length = 8.3cm, PT = 0.8cm. Left kidney bipolar length = 10.1cm, PT = 1.1cm. No stones r hydronephrosis demonstrated bilaterally. No perinephric fluid collection. Urinary bladder is partially distended. No mass or calculus seen within. Visualised bilateral psoas muscles are normal. No mass or intraabdominal collection noted Free fluid noted at perihepatic and perisplenic region. Incidental finding: Right pleural effusion. Impressions: 1. Fatty liver with hepatomegaly. 2. Bilateral renal parenchymal disease. 3. Right pleural effusion and mild ascites. Exam Performed On 30/04/2026 08:06 By : DRJASONW2 - Jason Wong ,Dr Report Prepared On : 30/04/2026 09:10 By Radiologist : DRKANMANI2 - Kanmani, D Report Authorized On : 30/04/2026 09:10 By Radiologist : DRKANMANI2 - Kanmani, This is the previous report in april