Sunday, 27 June 2021

spo2 =78 !!! but asymptomatic???

51 year female ,anganwadi worker, came with cco 
  Epigastic pain :: 3 days 
  Pedal oedema:: 3days
 Epigstric pain associated with sob ::2 days 

H o p i 
Pt. Apparently  asymptomatic  3days back
Then she developed sudden  onsetof epigastric pain without any vomiting or loose stool history, which subsided with medication.
Pedal bl oedem is pitting type extending upto shin since 2 days not associated with any decreased urine output . 
H/o immobilization  present 
No h/o decreased urine output, fever,cough, palpitaions, chestpain ,headache, orthopnea,pnd.
KC of HTN was  on   medication . Bit discontinued  it.
Not a kc of dm,CVA, epilepsy,Asthma.
Surgical history:
Her lower left limb went under Recurent operations. 
She had femur fracture in 2005,implant was placed
 Implant removal done in 2019 and 6days after implant removal she did weight bearing so she again had fracture
 Implant is placed again.

Patient  is a vegetarian by diet, she has loss of APPETITE regular bladder and bowel movements,no allergies and no addiction s
No family h/o DM,HTN ASTHMA,EPILEPSY.
CvA,TB.
Moderately built and moderate nourished 
V i t a l s: 
 Temp:  98F
Pr:  126  bpm
SpO2 :78 % on room Air
Rr : 26cpm
Bp: 110/70
Grbs : 168
SpO2 on 2lt O2 =98%

Dx

?Right heart failure 
secondary 
to cor pulmonale
?HFpEF
?PTE sub massive
 
Kc HTN

Tx
Inj LASIX 40mg BD
Iv fluids Ns  with OPTINEURUM@75ml /hr.
O2 inhalation  @2-4lit/min to maintain spO2 >92%.
T. TELMA 40 mg po OD
Advice: GRBS 6th hry CHARTING .


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