General medicine case 9

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A 50 old yr female patient she is House wife presented to opd with chief complaints of shortness of breath 10 days back

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 9 yrs back then she had fever visited to local hospital and blood investigations were done she was diagnosed with Diabetes mellitus and hypertension and she has been taking medication for DM and hypertension since 9 yrs

 On 6th March 2021 she was noticed pedal edema which was pitting type and gradual on onset and at that time she came to opd in semiconscious state and with profuse sweating and she was discharged from our hospital 11th March 

she had pedal edema 6 months back and facial puffiness on and off 2 months back and  cough since 3 months  shortness of breath 2 months back  which aggrevated since 10 to 15 days back presented to opd on chief complaint of shortness of breath on rest since 10 days back she was admitted the on 8th December 2021 they came back to hospital and decreased urine output since 1 and half month and attender constantly saying that she used to have giddiness and fell down due to hypoglycemia

Daily routine before illness:- she used to wake up a 4 o clock in the morning do her household work  and pack tiffin for her children she used to have breakfast by 10 that is rice and dal then she used to have her lunch by 2 then go farm she was daily wage labourer she used to work in paddy field like sowing the seeds, harvesting and come back to home by 6 then she used to prepare dinner for family members then have the dinner by 8 or 9 

Daily routine after illness :-  inspite of her weakness she used to do all her household work since 1 yr she is not going to paddy field she stopped working 

PERSONAL HISTORY

Diet is mixed

She had loss of appetite 6 months back then presently her appetite is normal

Bladder movements decreased urine output since 1and half month

Bowel movement regular

Addictions :- patient has habit of eating paan since 25 yrs

FAMILY HISTORY

No history of similar complaints in the family

TREATMENT HISTORY :

Atenolol 50 mg

Amlodipine 5 mg for Hypertension

Glimperide 2 mg

GENERAL EXAMINATION:

 Patient was concious coherent and coperative well oriented to time place and person.

- pallor present

-No clubbing

-No cyanosis

-No icterus

-No generalized lymphedenopathy

-presently no pedal edema

 VITALS

Temperature : afebrile

Pulse rate:  102 beats per min

Respiratory rate : 22 cycles per min

Bp :170/ 110mm of Hg

SYSTEMIC EXAMINATION

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 6th intercostal space 

Ausculation:

S1 ,S2 Heard

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal.

 

Provisional diagnosis :- Dilated cardiomyopathy, diabetic nephropathy and right pleural effusion with iron deficiency anemia

Treatment :

1) INJ. LASIX 20mg/hr continuous infusion

2) TAB. MET XL 50 mg - PO - BD

3) TAB. ECOSPRIN 150 mg - OD

4) TAB. CLOPIDOGREL 75 mg - OD

5) TAB. ATORVAS 20mg - OD

6) Daily weight monitoring

7) SpO2/BP/PR/RR - monitoring 2nd hourly

8) Head end elevation

9) O2 supplementation SOS

10) INJ. IRON SUCROSE in 100 ml NS IV weekly twice

11) TAB. OROFER XT 100MG OD

12) INJ. HAI s/C TID 

13) TAB. METALAZONE 5mg OD

14) INJ. ERYTHROPOETIN s/c weekly twice 

15) TAB. CINOD 10mg OD

16) NEB. ASTHALIN 4 respules stat