Thursday, December 16, 2021

A 70 YEAR OLD FEMALE PATIENT

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

A 36 YEAR OLD MALE WITH EDEMA OF THE THROAT

 Amc bed 1 A 36 year old male patient who is a watchman in a govt. Hospital 1km far from home came to the casuality with swelling of the ton...