Internship Medicine Posting

Medicine Intern Log

      Hello everyone, I'm a medical intern, and recently started my Medicine posting. This blog is to share my experience and the cases I come across during this period. 

CASE

      A 46 years old male patient came with complaint of chest pain for 30 minutes yesterday evening and shortness of breath on exertion. 

HOPI:

Patient was apparently asymptomatic 5 years back then he developed pedal edema which was pitting type associated with abdominal distension and shortness of breath grade IV and got admitted outside hospital for 20 days and got discharged. 

History of chest pain, shortness of breath 3 years back and got admitted, angiogram was done and clot was removed, got discharged. 

History of similar complain 1 year back and got admitted at KIMS Narketpally. 

Yesterday he complained of chest pain which was pricking type, radiating to left arm which lasted for 30 minutes and associated with sweating. No history of palpitations. 

History of shortness of breath on exertion (immediately after 3 to 4 steps) and relieved on rest. 

No history of syncopal attack. 

No history of pedal edema. 

No history of pain abdomen. 

No history of decreased urine output. 

No history of constipation or diarrhoea. 

Angiogram report

Past History:

No history of HTN, DM, asthma, epilepsy. 

Personal History:

He is a driver, agricultural labour by occupation. 

Normal appetite. 

Bowel and bladder movements are regular. 

No known allergies. 

Chronic alcoholic. 

 

Family History:

Not significant

GENERAL EXAMINATION

Patient is C/C/C 

Obese 

Pallor - absent

Icterus - absent

No cyanosis, clubbing, lymphadenopathy

Temp - afebrile

BP - 130/80 mmHg

Pulse rate - 78 bpm normal in rate rythm, volume

RR - 20 per minute

SPO2 - 98%

GRBS - 134 mg%

SYSTEMIC EXAMINATION

CVS:

Chest normal in shape

Apex beat seen at left 5th intercoastal lateral to mid - clavicular line

S1 S2 heard 

CNS:

Higher mental functions - normal

Cranial nerves - intact 

Motor system examination - normal

Respiratory system:

Trachea - central

NVBS - heard

Bilateral fine basal crepitations heard

Abdomen:

Shape - obese 

No tenderness 

Hernial orifices -  free

No organomegaly 

Diagnosis:

Heart failure with reduced ejection fraction (ef-28%) 

 

Investigations:

1) CBP

2) CUE

3) RBS

4) LFT

5) RFT

6) Chest X-ray

7) ECG

8) 2D Echo

:

Treatment Given:

1) Tab Ecospirin gold OD

2) Tab pantop 40mg IV OD

3) Inj Lasix 40mg IV BD (if SBP > 110) 

4) Head end elevation

5) O2 inhalation if required to maintain SPO2 greater than 90%

6) Salt and fluid restrictions

7) BP PR SPO2 monitoring every 2 hours

Advise at discharged:

1) Head end elevation

2) Salt (<2g/day) and fluid (<1lit/day)

3) Tab Ditorflex 10/50mg P.O BD

4) Tab Pantop 40mg P.O OD

5) Tab Ecospirin gold OD

6) Tab raniprill 1.25mg OD

Follow Up:

When required