GM Blog series

Roll no:167;K.Kavya

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


       15-12-21

Unit-2 NEW ADMISSION

A 70-year-old female Patient came to the OPD with the complains of Shortness Of Breath since 15 days aggravated since yesterday 
Complains of numbness 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 , shortness of breath, chest discomfort went to hospital and diagnosed with coronary artery disease 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 medications. 

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 numbness sensation all over the body
 
Past history:
Known case of CAD -left coronary artery. 
Not a known case of:diabetes, 

Personal history:married
Diet-mixed
Appetite-less
Sleep- adequate

Family history:
Not significant. 

General Examination:
Patient is conscious, coherent and cooperative
no pallor
no icterus
no clubbing
no cyanosis
Lymphadenopathy:absent
Pedam edema:absent
Vitals:
temperature 97.5°F
Pulse rate 60 BPM 
Respiratory rate 18 CPM
BP 100/70 MMHG 
SPO2  98mmHg

Systemic examination:
CVS -
S1 S2 +;no murmers;no palpitations. 
Respiratory system-
 Dyspnoea- present
Abomen-
P/A- soft non-tender
CNS - 
 No neurological disorders

Provisional diagnosis:
Coronary Artery Disease with Triple  Coronary disease
severe LV dysfunction with Cardio-renal syndrome. 

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 . 

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