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
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
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