This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.
DEIDENTIFICATION -
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CASE DISCUSSION -
65 year old female homemaker by occupation came to the casualty with C/o Pedal Edema, SOB, Left & Right Loin Pain since last 1 week.
HOPI -
Patient was apparently asymptomatic 1 week back, then she had SOB GRADE-IV not associated with cough; Pedal edema below knee; Right and left loin pain, non radiating.
No H/o palpitations, sweating, cold, fever.
No H/o burning micturition, decreased urine output, hematuria, dysuria, hesitation while passing urine.
Past History -
Not a k/c/o DM, HTN, CVA, CAD, TB, Epilepsy.
Personal History -
Married
Occupation- Homemaker
Diet: mixed
Appetite: Decreased since last 1 week.
Bowel and bladder : Normal
Addictions: Toddy drinker(Stopped 5 years back)
Family History -
No similar complaints in the family.
General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent and cooperative.
Built & nourishment-Moderate
Edema- Pitting type, below knee.
No pallor
No cyanosis
No icterus
No clubbing
No lymphadenopathy.
Systemic Examination -
CVS :
S1 S2 present
No Murmurs
No Thrills
RESPIRATORY SYSTEM-
Dyspnoea- Grade IV
Wheeze- Absent
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard
ABDOMEN:
Shape of abdomen: Obese
Soft, non tender, no organomegaly present.
No rigidity or guarding.
CNS :
NFND, HMF intact
Reflexes - Normal
Investigations-
Provisional Diagnosis-
? Heart Failure
Treatment-
Inj. Lasix 40mg IV/Stat
Tab Ecosporin AV PO/HS
Inj. Pan 40mg IV/Stat
Tab Met XL 12.5mg PO/OD
Vitals Monitoring
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