A 60 year old male with SOB and pedal edema
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The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient.
CHIEF COMPLAINTS :
A 60 year old male resident of Nalgonda farmer by occupation came to OPD with chief complaints of
Bilateral Pedal edema since 2 years
Shortness of breath since 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 years ago then he developed bilateral pedal edema which is pitting type 2 years back.
Associated features :
Low back ache since 2 months
Burning micturition since 2 months
Not associated with fever , chills and vomitings
History of shortness of breath since 2 days which aggregates on lying down and relieves on medication and sitting .
COURSE OF ILLNESS :
19 th dec 2022
Admitted for dialysis and underwent dialysis for 4 sessions then he developed shortness of breath and admitted in ICU and stabilised and discharged
On 1 st Jan 2022
Patient developed shortness of breath on 1 st Jan which aggravated on lying down and relieved on sitting position
On 2 nd Jan he presented to the hospital
DAILY ROUTINE :
Patient wakes up at 5:30 am and then he heads towards the farm and spends time and will have his first meal at around 9 am and takes rest and spends time in farm or around his place and will have lunch by 1:30 and takes rest from then and he will have his 3 rd course meal at 7:30 at the night and heads to sleep
PAST HISTORY:
Patient is a k/c/o diabetes since 5 years and on glimipride 1 mg
K/c/o hypertension since 2 years and on T Stamlo 5 mg
Not a known case of epilepsy , asthma and TB
PERSONAL HISTORY:
Appetite - reduced
Diet - mixed
Bowel and bladder movements - regular
Sleep - adequate
Addictions - history of smoking and alcohol consumption present but now stopped
Family history: not significant
Treatment history :
On Glimiperide 1 mg since 5 years
And T stamlo 5 mg since 2 years
No known drug allergies
No history of any major surgeries
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative, well oriented to time place and person
Moderately built and nourished
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - no palpable lymph nodes
Edema - bilateral pitting edema is present
VITALS :
Temperature - a febrile
BP - 140/70 mmhg
RR - 18 cpm
PR - 88 bpm
Spo2 - 98%
SYSTEMIC EXAMINATION:
CVS examination:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Per Abdominal examination:
On Inspection
Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.
On Palpation
Soft, non tender, no organo megaly.
On Auscultation
Bowel sounds heard
CNS :
No focal neurological disorder found
Normal speech
TREATMENT:
4 SESSIONS OF HEMODIALYSIS WAS DONE
T NODOSIS 500MG BD
T LASIX 200 MG PO BD
T NICARDIA 20MG PO TID
INJ HAI 6 UNITS TID BEFORE MEALS BP AND GRBS MONITORING 6 TH HRLY
CAP BIO D3 PO OD
Tab SHELCAL 500 MG PO OD
Tab OROFER XT PO OD
IN EPO 5000 IU WEEKLY ONCE
INJ IRON SUCROSE
3/1/23
O/e
Patient is conscious coherent cooperative
Bp- 140/80 mmhg
PR - 88bpm
CVS - s1 s 2 heard
RS - BAE +
Per abdomen - soft and non tender
Cns - no focal neurological deficits
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