120-S.Nikhil kumar casestudy-2


50 yr old female ,resident of farmer by occupation came to the casuality with
 c/o SOB( Grade II -III) since 3 days
B/L pedal edema since 8 months (on &off) subsiding with medication & worsening since 1 week 
Past History:-
Patient was her usual self 15 yrs back  ; then she had c/o SOB and was taken to hospital where angiogram (coronary) was done and      7 yrs back Mitral valve replacement was done (she was on regular medications since then )
H/o B/L pedal edema ,pitting type and H/o vomitings (2/3 episodes per day ) on &off since 8 months 
K/c/o DM since 4 yrs 
H/o similar complaints in the past
Blood transfusion done at the time of surgery (MVR)
Dietary history:-
Diet - Mixed
Appetite - Normal
Sleep -adequate
Bowel and bladder movements - Regular
No h/o burning micturition
No addictions

General Examination:-
Patient is conscious ,coherent and cooperative 
Moderately built and nourished 
 No pallor , icterus , cyanosis and lymphadenopathy 
Edema - present

Vitals:-
Afebrile
BP - 130/80 mmHg
PR 109 bpm
RR 36cpm
 
Systemic Examination:-
B/L air entry present
S1,S2 heard
Apex beat at 6th ICS lateral to Mid clavicular line 
Parasternal haeve present 
Palpable p2 
JVP raised
Dyspnea (grade 2 - grade 3)

Investigations done - 
ECG , Hemogram , PT , APTT ,CUE ,RBS , LFT ,RFT
Provisional diagnosis:-
Post op MVR 7 yrs back ? RHD i.e,Rhuematid Heart disease.

Treatment:-
Fluid restriction < 1 lt /day
Salt restriction < 2gm/day
Inj. LASIX 40mg BD
Tab. MET-XL 25 mg BD
Tab. ACITROM 1mg OD /PO
Tab. ECOSPRIN 75 mg OD /PO
BP/PR/Temp./Spo2 monitoring
Tab.RAMIPRIL 2.5 mg OD/PO
Tab.ATORVASTATIN 40mg OD/PO

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