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
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