A 70-year-old female Patient came to the OPD with the complains of SOB since 15 days aggravated since yesterday
Complains of tingling sensation all over the body since 15 days
History of present illness:
Patient was apparently a symptomatic four years back then in January 2018 she developed vomitings SOB chest discomfort went to hospital and diagnosed with CAD(LAD) and was referred to higher Centre -Angiogram was done and stent was placed
She is on regular medication till two years
After follow-up, she stopped taking medication and was only taking herbal medication for joint pains
Two months back she had a similar episode and diagnosed with CAD(RCA) -Angiogram was done, revealed triple vessel disease
Since 15 days patient had SOB associated with tingling sensation all over the body
no chest pain
no palpitations
no Pedal Oedema
Past illness:
known case of CAD S/P PTCA
No DM/HTN
Personal history:
married Home maker by occupation appetite normal regular bowl and bladder moment no allergies no addictions
No significant family history
General examination :
patient is C/C/C
Pallor
vitals:
temperature : 97.5°F
Pulse rate : 60 BPM
Respiratory rate : 18 CPM
BP : 100/70 MMHG
SPO2 : 98 @ RA
CVS: S1 S2 +
Respiratory system : NVBS+
P/A- soft non-tender
CNS - NO FND
Provisional diagnosis
k/c/o CAD TVD (post PTCA)
severe LV dysfunction with ?Cardio-renal syndrome type II
INVESTIGATIONS:
Hb: 8.8
Tlc: 8400
Plt.count: 2.34
CUE:
alb +
Pc: 3 to 4
Ec: 2 to 3
LFT:
TB: 0.96
DB: 0.20
AST: 17
ALP: 132
ALB: 1.31
RFT:
Urea: 71
Creatinine: 2.6
UA: 10.2
Na+ : 146
K+ : 3.1
Cl- : 96
ABG:
PH: 7.55
PCO2: 28.6
PO2 : 72.4
HCO3- : 25.1
ST. HCO3- : 27.4
SO2 : 94.3
ECG
Plan of Treatment :
Fluid Restriction 1 L per day
Salt restriction less than 2.4 g per day
Injection Lasix 40 mg/IV/BD
T. ECOSPORIN-Gold 75/40 MG/PO/HS
T.CARDIVAS 3.125 mg/PO/OD
T.PAN 40 MG/PO/OD (BBF)
T. B-COMPLEX PO/OD
Strict I/O charting
Monitor vitals hourly
