50F FOLLOW UP CASE OF ATRIAL FIBRILLATION

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input..

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Patient came with the c/0

-Fever & chills since 3 days,

(intermittent) relieved after taking medication

c/o palpitations since 2-3 days

-Difficulty in breathing since 6 days.

Heaviness in chest since 6 days

-B/L pedal edema on and off(pitting type) since 6 months

-Burning micturition (+)

HOPI

Patient was apparently asymptomatic 6 months back then she had c/o palpitations followed by she had c/o shortness of breath on exertion later progessed to Grade 4 for which she got admitted in our hospital and was diagnosed to have Atrial fibrillation with fast ventricular rate and was managed conservatively. She was alright for next 3 monthly then since 2 months she had complaints of palpitations on and off.

No c/o chest pain / syncopal attacks / orhtopnea / PND

No c/o involuntary movements/tingling parasthesia

Past history

N/k/c/o HTN /DM / TB/ ASTHMA,CAD, EPILEPSY

PERSONAL HISTORY-

DIET: MIXED

APPETTITE:NORMAL

BOWEL AND BLADDER: REGULAR

SLEEP: ADEQUATE

NO ADDICTIONS

GENERAL EXAMINATION-PATIENT IS CONSCIOUS.COHERENT.COOPERATIVE,WELL ORIENTED TO TIME, PLACE,PERSON

MODERATLY BUILT AND NOURISHED

NO PALLOR ,ICTERUS , CYANOSIS, KOILONYCHIA,GENERALIZED LYMPHADENOPATHY OR PEDEL EDEMA.

VITALS-

TEMPERATURE-98.6 F

PR-112BPM

BP-100/60 MMHG

RR-16CPM

GRBS 120MG%

SYSTEMIC EXAMINATION-

CVS-S1S2 HEARD,NO MURMURS

RS-BAE+,NVBS HEARD

CNS-NFND,HMF INTACT

P/A-SOFT,NON TENDER,NO ORGANOMEGALY

PSYCHIATRY OPINION

Psychiatry opinion was taken I/V/O anxiety and atrial fibrillation precipitation by emotional factors and noise

Impression -moderate depression with adjustment issues

Patient was counselled and psychotherapy was given

INVESTIGATIONS

DIAGNOSIS

Chronic atrial fibrillation reverted to normal sinus rhythm with moderate clinical depression

TREATMENT GIVEN

TAB ECOSPRIN 75/10 PO/HS @9AM

TAB MET XL 25MG PO/BD

TAB.SERTRALINE 25MG PO OD AT 8 AM FOR 1 WEEK

BRIEF PSYCHOTHERAPY WAS DONE

ADVICE AT DISCHARGE

TAB ECOSPRIN 75/10 PO/HS @9AM

TAB MET XL 25MG PO/BD

TAB.SERTRALINE 25MG PO OD AT 8 AM FOR 1 WEEK

TAB CLONAZEPAM MD 0.5 MG PO/SOS ( IF PATIENT IS RESTLESS OR ANXIOUS)

FOLLOW UP

REVIEW TO GENERAL MEDICINE OPD AND PSYCHIATRY OPD AFTER 1 WEEK

Comments

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