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. 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

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

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