60Yr old female

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PRESENTING COMPLAINTS:

C/O of cold since 5 days

C/O alleged history of fall on leftshoulder 4days ago

C/O breathlessness since 4 days

HISTORY OF PRESENTING ILLNESS:

A 60 year female presented to casualty with complaints of  

Alleged fall from bed in sleep on left shoulder followed by pain at left shoulder and right side of chest , associated with movement restriction and pain . History of breathless of grade 1 MMRC , which was progressed to MMRC 3. 

H/o orthopnoea 

No history of chest pain /palpitations/no PND / burning micturation / cough . History of cold since 5 days not associated fever , body pains , myalgia

PAST HISTORY:

Not a k/c/o Hypertension/ Tuberculosis/Asthma / thyroid disorders/ CVD/ CAD

Alleged history of fall on left shoulder 1 yr ago

GENERAL PHYSICAL EXAMINATION

Patient was consious ,coherent ,cooperative and well oriented to time ,place , person

Pallor present

B/L pedal edema present i.e pitting type

No cyanosis , clubbing, lymphadenopathy 

VITALS: 

At the time of presentation 

Temperature:98.7F

Bp :220/100mmhg

PR: 112bpm

RR: 24cpm

COURSE IN HOSPITAL 

A 60 year female presented to casualty with complaints of  

Alleged fall from bed in sleep on left shoulder followed by pain at left shoulder and left side of chest , associated with movement restriction and pain . History of breathless of grade 1 MMRC , which was progressed to MMRC 3. 

Saturation was  

On clinical examination:

CVS: 

S1 , S2 heard 

No thrills 

No murmurs.

Respiratory system: 

Trachea: central 

Dyspnea: present grade 3 MMRC 

Bilateral air entry present 

Crepts heard in Bilateral infra axillary area 

Abdomen : 

Shape : obese (distended) 

No tenderness

No palpable mass

No free fluid , bruits 

Liver palpable ( ? Hepatomegaly) 

Spleen not palpable

Bowel sounds heard 

CNS:

Patient is conscious 

Speech normal

Memory intact 

Power tone normal ( both upper and lower limbs) 

No signs of meningeal irritation.

Reflexes : normal.

On 13/10/22According to USG reports- there is B/L Pleural effusion , pericardial effusion

Diagnosis : 

Heart failure with preserved ejection fraction

With denovo hypertension 

With dimorphic anemia

TREATMENT: 

1. Inj. LASIX 40mg for 4 days

2. Fluid restriction <1.5 liters /day

3. Inj. B12 1000mcg IM/OD

4.syp.potclor 15ml/po/bd in 1 glass of water for 3 days

5.normal diet with salt restriction < 2gm / day

6. Tab. Aldactone 25mg po/od for 3DAYS

7. Tab . Cinod10mg po/bd for 4 days 

8. Met.xli 25mg po/od for 3 days