65 Y Female
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
A 65 Years Old Toddy Seller came with C/O Chest Pain Since 5 days
Increased Pedal Edema Since 10 days
HOPI :
Pt was Apparently asymptomatic Till 7 Years back
In 2015 she Developed Pain in Chest for which she went to Hospital and ? Inferior Wall MI was diagnosed & PTCA Was Done. At the Same Time She was diagnosed with DENOVO
DM2 & HTN for which She was Prescribed Medication.
In 2019 She Developed SOB on Exertion ; Pedal Edema & Anasarca for which she went to Hospital and Diagnosed with CCF with Anemia for Which PRBC Transfusion was Done & Discharged with Diuretics
10 days back She stopped Taking Diuretics after which started Developing Increased Pedal Edema & Pain in Chest
Pedal Edema - B/L ; Pitting Type & Upto Knees
Pain in Chest - Diffuse, Pricking Type, Associated with SOB, Sweating & Palpitations
Past History :
At the age of 15years of age She had Headache for which she used NSAIDS & HERBAL MEDICATION
K/C/O Type 2 Diabetes Since 7 Years and on Regular Medication - Tab.GLIPIZIDE 5MG PO OD
K/C/O HTN Since 7 Years and on Regular Medication - Tab.TELMA 40MG
K/C/O CAD 7 Years back & PTCA Was done and on Regular Medication - Tab.CLOPIDOGREL 75MG PO OD & LASIX 40MG PO BD
Personal History :
Mixed Diet
Appetite - Good
Sleep - Adequate ji
Bowel & Bladder - Regular
Addictions - Nil
Investigations :
ECG :
2D Echo :
USG ABDOMEN :
DIAGNOSIS : CCF with H/O Old IWMI for which S/P PTCA with K/C/O HTN & DM2 Since 7 Years
Treatment Given :
T.LASIX 20Mg PO BD
T.CLOPITAB 75MG PO OD
T.ATORVAS 40MG PO HS
T.TELMA 40MG PO OD
T.GLIPIZIDE 5MG PO OD
Discharge Summary :
Brief course in the Hospital :
A 65 Years Old Toddy Seller by Occupation came with Complaints of Chest pain since 5 days & Increasing Pedal Edema since 10days which started Increasing after she Stopped T.LASIX 20MG 10 days Back.Vitals are Stable at the time of admission.On Further Evaluation She was Diagnosed with CCF with H/O Old IWMI for which S/P PTCA with K/C/O HTN & DM2 Since 7 Years and Managed Accordingly. Vitals are Stable at the time of Discharge.
Advise at Discharge :
T.LASIX 20Mg PO BD
T.CLOPITAB 75MG PO OD
T.ATORVAS 40MG PO HS
T.TELMA 40MG PO OD
T.GLIPIZIDE 5MG PO OD
Review : Review to General Medicine OPD after 2 Weeks
