Prefinal General medicine practical

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Date: 19/12/2021

A 70-year-old female Patient came to the OPD with the complains of SOB and tingling sensation all over the body since 15 days.

History of present illness:

Patient was apparently  asymptomatic 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 was 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 (grade 2) associated with tingling sensation all over the body

 no chest pain 

 no palpitations

 no Pedal Oedema 

DAILY ROUTINE:

WHEN SHE WAS ALRIGHT

She used to wake up at 6:00am and used to have 

tea at 7:00am and breakfast (rice) at 9:00am and go to work then around 1:00pm she used to have her lunch (rice) and around 6:00pm she used to return from work and then at 8:30 she used have her dinner (rice) and at 9:30pm she goes to bed.

CURRENT DAILY ROUTINE:

She wakes up at 6:00am and  drinks tea at 9:00am she skips breakfast and have her lunch at 1:00pm and dinner at 8:30pm. 

History of past illness:

CAD S/P PTCA

No DM/HTNP

In her childhood because of chicken pox infection she lost her left eye vision.

Personal history :

Married Home maker by occupation appetite normal regular bowl and bladder moment no allergies no addictions

No significant family history.

GENERAL EXAMINATION:

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

INVESTIGATION :-

HEMOGRAM:

COMPLETE URINE EXAMINATION:

ULTRASOUND:

Provisional diagnosis 

k/c/o CAD TVD (post PTCA) 

severe LV dysfunction with ?Cardio-renal syndrome type II

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:18/12/2021