60yr Female with SOB

This is an online E logbook to discuss our patient’s de-health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.

PRESENTING COMPLAINTS:

C/O of cold since 5 days

C/O alleged history of fall on leftshoulder 4days ago

C/O breathlessness since 4 days

HISTORY OF PRESENTING ILLNESS:

A 60 year female presented to casualty with complaints of

Alleged fall from bed in sleep on left shoulder followed by pain at left shoulder and right side of chest , associated with movement restriction and pain . History of breathless of grade 1 MMRC , which was progressed to MMRC 3.

H/o orthopnoea

No history of chest pain /palpitations/no PND / burning micturation / cough . History of cold since 5 days not associated fever , body pains , myalgia

PAST HISTORY:

Not a k/c/o Hypertension/ Tuberculosis/Asthma / thyroid disorders/ CVD/ CAD

Alleged history of fall on left shoulder 1 yr ago

GENERAL PHYSICAL EXAMINATION

Patient was consious ,coherent ,cooperative and well oriented to time ,place , person

Pallor present

B/L pedal edema present i.e pitting type

No cyanosis , clubbing, lymphadenopathy

VITALS:

At the time of presentation

Temperature:98.7F

Bp :220/100mmhg

PR: 112bpm

RR: 24cpm

COURSE IN HOSPITAL

A 60 year female presented to casualty with complaints of

Alleged fall from bed in sleep on left shoulder followed by pain at left shoulder and left side of chest , associated with movement restriction and pain . History of breathless of grade 1 MMRC , which was progressed to MMRC 3.

Saturation was

On clinical examination:

CVS:

S1 , S2 heard

No thrills

No murmurs.

Respiratory system:

Trachea: central

Dyspnea: present grade 3 MMRC

Bilateral air entry present

Crepts heard in Bilateral infra axillary area

Abdomen :

Shape : obese (distended)

No tenderness

No palpable mass

No free fluid , bruits

Liver palpable ( ? Hepatomegaly)

Spleen not palpable

Bowel sounds heard

CNS:

Patient is conscious

Speech normal

Memory intact

Power tone normal ( both upper and lower limbs)

No signs of meningeal irritation.

Reflexes : normal.

On 13/10/22According to USG reports- there is B/L Pleural effusion , pericardial effusion

Diagnosis :

Heart failure with preserved ejection fraction

With denovo hypertension

With dimorphic anemia

TREATMENT:

1. Inj. LASIX 40mg for 4 days

2. Fluid restriction <1.5 liters /day

3. Inj. B12 1000mcg IM/OD

4.syp.potclor 15ml/po/bd in 1 glass of water for 3 days

5.normal diet with salt restriction < 2gm / day

6. Tab. Aldactone 25mg po/od for 3DAYS

7. Tab . Cinod10mg po/bd for 4 days

8. Met.xli 25mg po/od for 3 days

Comments

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