70 yrs M with CAD wirh HFrEF with( EF 35%) LAD with AF with FVR with LBBB

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case I have seen:

Unit 6:

Case admitted on 27/2/2021.

Interns 

Swarna

Juveria

K.Divya

Nikhil reddy

 B.Manivarma


Dr. Manasa(pgy1)

Dr. A. Vaishnavi (pgy2) 

Dr.  Sai Radha(pgy3)

Dr. Arjun (asst. Prof) 

Dr.Praveen Naik( asst.prof)

Dr.Rakesh Biswas (HOD)

70 yrs farmer who stopped since 1 year due to low  chest pain and shortness of breath came with chief complaint of palpitations since 1 year shortness of breath since 3  and chest pain since 3 months aggravated since 15 days

History of present illness :
Shortness of breath since 3 months progressed from grade 2 -4 associated with chest pain- burning type and palpation +
Epigastric pain since 3 months ass with postprandial  abdominal distension present belching + nausea+
History of hospitalization 2 months back for abdominal pain in khammam 

Past history :
Not a known case of DM HTN TB Asthma Epilepsy 

Vitals:
PR -96
BP- 150/100
RS- BAE +
CVS -S1S2+
CNS- NAD

Provisional diagnosis :
CAD with HFrEF with (EF 35%)LAD AF with  FVR with LBBB

Investigations 


Treatment day 1:
1.Fluid restriction <1.5 L day
2.T. Pantop 40 mg OD
3.T. Lasix 40 mg PO/OD 
4.T. MET XL 40 mg PO/OD 
5.Syrup Sucralfate 10 mL/TID
6.T. Ecospirin AX 75/100 mg PO/OD 
7.Bp charting 2 hrly
8.Strict I/O charting 

Treatment day 2:
1.Fluid restriction <1.5 L day
2.Salt restriction <2 g day
3.T. Pantop 40 mg OD
4.T. Lasix 40 mg PO/OD 
5.T. MET XL 40 mg PO/OD 
6.Syrup Sucralfate 10 mL TID
7.T. Ecospirin AX (75/100) mg PO/OD 
8.Ultracet PO /Bd
8.Bp charting 2 hrly
9.Strict I/O charting 

Treatment day 3:
Fluid restriction <1.5 L day
2.Salt restriction <2 g day
3.inj .Pantop 40 mg IV/BD
4.T. Lasix 40 mg PO/OD 
5.T. MET XL 40 mg PO/OD 
6.Syrup Sucralfate 10 mL /TID
7.T. Ecospirin AX (75/100) mg PO/OD 
8.Ultracet PO /Bd
9.inj. Buscopan 1 amp IV /SOS
10.Bp charting 2 hrly
11..Strict I/O charting 

Treatment day 4:
1.Fluid restriction <1.5 L day
2.Salt restriction <2 g day
3.T. Lasix 40 mg PO/OD 
4..Syrup Sucralfate 10 mL /TID
5.T. Ecospirin AX (75/100) mg PO/OD 
6.Ultracet PO /Bd
7.inj. Buscopan 1 amp IV /SOS
8. Surup mucaine gel 15  BF TID
9.Plan lo tab dilatiazam 30 mg po/TID
 10.Tab thiocolchicoside 4mg od


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