48 YEAR OLD FEMALE PRESENTING WITH PAIN IN ABDOMEN AND DISTENSION.

 

E LOG GENERAL MEDICINE


Hi, I am Rishitha, 3rd Sem Medical Student. 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 an ongoing case. I am in the process of updating and editing this ELOG as and when required.

*Elog made under guidance of Dr. Bhavya (Intern)



CASE SHEET


 48 YEAR OLD FEMALE PRESENTING WITH PAIN IN ABDOMEN AND DISTENSION.



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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