40 year old with pain abdomen and palpitations

 

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Chief complaints 

40 yr old female who is a labourer presented to the OPD with the chief complaints of pain abdomen.

History of presenting illness

1)C/O pain abdomen since 2 days in the right hypochondriac region.

2)H/O palpitations 5 yrs back and was admitted for 5 days in an outside hospital where she received shock therapy. She has been on T. Amiodarone 100mg since then.

3) shortness of breath and leg pain for walking a short distance ,the day before presentation. Relieved on taking rest.

4) 

Past history

H/O hysterectomy 10 years back.

Martial history:

Married for 25 years

Conceived 3 children

Personal history

Diet:mixed

Appetite:normal

Bowel and bladder:regular 

Addictions:none

General examination

The patient is conscious,  coherent and cooperative.

PALLOR IS PRESENT.

At presentation:

BP-90/50 mmhg

PR-97bpm

RR-12/min

CVS- JVP +, S1S2 +, S3+, S4+, Palpable P2,                          parasternal heave present.

         Diffuse apex beat in 6th intercostal space 1            cm lateral to mid central line.

CNS- no focal neuron deficits.

SpO2- 97%

Per abdomen examination:: soft, non tender.

PROVISIONAL DIAGNOSIS

DCMP with EF-30% secondary to ischemic heart disease.

TREATMENT

1) Inj LASIX 40mg IV/BD

2) Strict I/O charting

3) Fluid restriction< 2lt/day

4) salt restriction <1.5gm/day

5) Inj. PAN 40mg IV/OD

6) Syp. CREMAFFIN 10ml/PO/BD

7) Inj. BUSCOPA  10mg/IV/ SOS

8) Daily weight monitoring

9) T. ASPIRIN 75mg PO/OD

10) T. CLOPITAB 75mg PO/OD

11) T. ATORVA 40mg PO/OD

12) T. AMIODARONE 100mg PO/OD