70 year old male with SOB ,vomitings and pedal edema

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Chief complaints:

75 years old male came to OPD with cc of pedal edema since 1month,shortness of breath since 20days,vomitings since 10days 

History of present illeness:

Patient was apparently asymptomatic 1month back ,then he developed bilateral pedal edema which is insidious in onset gradual in progression upto the knee and pitting type edema.

Patient was asymptomatic 20days back then he developed shortness of breath and pedal edema for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital.

With no aggrevating and no relieving factors.

He also had shortness of breath since 20days which is sudden in onset gradual in progression and grade 4 aggrevating on doing work, walking and temporarily relived on medication

He had history of vomitings which is sudden in onset,non billous type,not blood stained,4episods of vomitings per day(he vomit soon after taking food or juice)

And also he had productive cough.

No history of fever,burning micturation,decresed frequency of urination,poor stream,chills and rigor

No history of dark coloured urine

PAST HISTORY:

History of incidental finding of hypertension 20days back

He had history of TB 18years ago for which he had taken medication for 6months and TB symptoms get subsided

No history of diabetes, thyroid,epilepsy,asthma,

No history of any previous surgeries 

PERSONEL HISTORY: 

Diet:mixed

Sleep:regular but decresed since 10days 

Appetite:adequate but decreased since 10days 

Bladder and bowel movement: regular

Addictions:he started taking alcohol since 30years of age,daily 1quarter daily and his last alcohol uptake was 1 month back.

Dialy Routine:

75years old male previously he worked as farmer but now he stay in his home patient wake up at 4:30am morning and do his regular activities and he had breakfast with rice and vegetables curry at 7:30am and he stays in home at 1pm he had lunch(rice+vegetables curry)and had nap of sleep for about 30min and wake up and at 7pm had there dinner(some times chepati,rice,curry) and at 9oclock he sleep

FAMILY HISTORY:

No significant family history  

TREATMENT HISTORY:

No significant treatment history 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and we'll oriented with time,place,person

Pallor:present

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 

Pedal edema: bilateral pedam edema ,pitting type

Jvp Raised 

VITALS:

TEMP:97.2F

PR:80bpm

RR:21cpm

BP:130/80

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

MEASUREMENTS-

chest circumference

Transverse diameter is:26cm

Anteroposterior diameter is :16cm

Chest expansion:-

Tactile vocal phremitus(vibration)- present in all areas 

Percussion:-

                    Right                          left

Supraclavicular- Resonant (R) (R)

Infraclavicular- (R) (R)

Mammary-R R

Axillary- (R) (R) 

Infra axillary- dull dull

Suprascapular- (R) (R)

Interscapular- (R) (R) 

Infrascapular- dull dull

Auscultation:-

                     Right.                       Left.

Supraclavicular- Normal vesicular 

                        Breath sounds (NVBS)

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary-decreased decreased                               

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- decreased decreased

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP -  Raised

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs

Per abdomen: 

On inspection:

Shape - flat

Abdomen moves equally with respiration. 

Umbilicus inverted

No scars and sinuses present. 

No visible pulsatios , no engorged veins

On palpation: 

No tenderness 

No rebound tenderness, no gaurding, no rigidity

No organonegaly

On percussion: 

No fluid thrill 

No shifting dullness

On Auscultation:

Bowel sounds heard

CNS EXAMINATION:

No focal neurological deficit 

Provisional diagnosis:

Acute on chronic CKD

Heart failure with reduced ejection fraction

B/L pleural effusion

Anaemia 

Thrombocytopenia 

Investigations :

CBP:

HBSAG:

BLOOD GROUPING:

SERUM CREATININE:

                                                                                   BLOOD UREA:

ANTI HCV antibodies 

HIV test:

USG::

2D Echo:

X RAY:

ECG:.                                                             

ABG:

CUE:

SERUM electrolytes:

Treatment :

1) inj LASIK20mg IV BD

3)CAP BIOD3 PER ORALLY OD

4)TAB OROFER XT PER ORALLY OD

5)TAB SHELCAL PER ORALLY OD

6)INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE