A 48 year old female with pain abdomen and distension.

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 my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!

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 asymptotic 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: - Not seen.

Icterus: - Not seen

Cyanosis - Not seen

Clubbing - Not seen

Lymphadenopathy - Not seen

Edema of foot - YES  



Dehydration - Not seen.



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 murmers




2. RESPIRATORY SYSTEM 
No dyspnoea
No wheezing
Position of trachea - central 
Vesicular breath sounds heard
No adventitious sounds

3. 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 TO BE ORDERED 

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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