48 year old female
This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very endThis is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
48 YEAR OLD FEMALE PRESENTING WITH PAIN IN ABDOMEN AND DISTENSION.
This is a case of 48 year old female who is a regular alochol consumer, came with the chief complaints of upper abdominal pain and distension since 20 days.
CHIEF COMPLAINTS
c/o upper abdominal pain and distension from past 20 days
SOB grade III - IV from past 15 days. Patient was asymptotic 4 months back and then she had developed SOB grade III - IV for which she went to a local hospital.
Date of admission : 30.07.2021
HISTORY OF PRESENT ILLNESS
Patient was asymptomatic 20 days back and has been doing her routine work without any limitations.
She then had developed abdominal pain and distension.
And SOB grade III - IV associated with orthopnoea, 15 days back, where she visited a local hospital.
And was prescribed medication and used the treatment for 10 days and stopped.
Heart palpitations sound positive.
HISTORY OF PAST ILLNESS
No h/o chest pain / giddiness/ syncope/ cough
No h/o vomiting
No h/o diarrhoea
No other specific complaints.
k/c/o
Diabetes Mellitus
PERSONAL HISTORY.
Appetite is Lost
Having Mixed diet
Bowels - Regular
Micturition - Normal
No known allergies
Regular consumer of Alcohol.
No other habits or addictions.
TREATMENT HISTORY
No relevant treatment history.
Physical Examination
Pallor: - Absent
Icterus: - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Edema of foot - PRESENT
Vitals-
Temperature - 98.6 °F
Pulse rate - 142/ min
RR - 18/ min
BP - 110/70 mm/Hg
SpO2 - 98%
GRBS - 212 mg%
Systemic Examination
1. CVS-
No thrills
S1 and S2 heard
No murmurs
2. RESPIRATORY SYSTEM
No dyspnoea
No wheezing
Position of trachea - central
Vesicular breath sounds heard
No adventitious sounds
3. PER ABDOMEN
Shape - Scaphoid
No palpable mass
Normal hernial orifices
No free fluid
No Bruits
Liver is not palpable
Spleen is not palpable
Bowel sounds heard.
4. CNS
Patient is Conscious and Coherent
Normal Speech
No signs of meningeal irritation
Cranial Nerves intact
Motor system reflexes are normal
Glasgow scale - 15/15
Normal Gait
PROVISIONAL DIAGNOSIS -
Persistent Atrial Fibrillation (AF) with RVR, associated with FVR (Forearm Vascular Resistance),
HfrEf 2° to CAD.
INVESTIGATIONS-
1. Hemogram
2. CUE
3. LFT
4. 2D Echo
5. Serum Creatinine
6. Serum Electrolytes
7. Blood Urea
8. USG
9. Blood Sugar
Fasting blood sugar
Post lunch blood sugar
10. APTT
11. Troponin
12. PTT
13. ECG
30/07/2021. 18:59 pm
31/07/2021. 7:50 pm
02/08/2021. 11:10 am
03/08/2021. 06:49 am.
TREATMENT GIVEN-
30.07.2021
Fluid restriction < 1 L/day
Salt restriction < 2 gm/day
Inj LASI 40 mg
Tab MET 25 mg
Inj HAI /s/c/ TID
Tab. DIGOXIN 0.25 mg/OD
Inj CLEXANE 40 mg.
31.07.2021
Inj LASIX 40 mg
Tab. Met Xl 25 mg
Tab. Ecosporin
Tab. Digoxin 0.25 mg
Tab. Clexane 40 mg
Tab. HAI
01.08.2021
Fluid restriction < 1 L/day
Salt restriction < 2 gm/day
Inj LASIX 40 mg
Tab. Met XL 25 mg
Tab. Ecosporin
Tab. Digoxin 0.25 mg
Tab. Clexane 40 mg
02.08.2021
Tab. LASIX
Tab. Met XL
Inj. CLEXANE 40 mg
Tab. Ecosporin
Tab. Digoxin 0.25 mg
Syprup Lactulose 15 ml
Tab. METFORMIN 500 mg
03.08.2021
Fluid restriction < 1 L/day
Salt restriction < 2 gm/day
Inj LASIX 40 mg
Tab. Met XL 25 mg
Tab. Ecosporin
Tab. METFORMIN 500 mg.
Syprup Lactulose 15 ml
Patient Status : DISCHARGED.
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