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