62yr/M with c/o pedal edema since 2years and SOB since 2 months (short case)

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Chief Complaints

62 year old male, farmer by occupation resident of Nalgonda, came to hospital with chief Complaints of

Pedal edema since 2 years

SOB since 2 months

History of Present Illness:

  Patient was apparently asymptomatic 2 years ago, then he developed SOB, pitting edema.

 SOB: grade 3, insidious onset gradually progressed and relieved on laying down, diurnal variation is seen, more at night time not associated with fever, cough and cold 

History of Past illness:

    Known case of Hypertension since 2 years, on medication Tab.Stamlo 5mg OD.

    Known case of Diabetes milletus since 3months on medication Tab.Glimipride 1mg BD.

    No H/o chest pain, chest tightness.

    Not a known case of Epilepsy, CAD, Asthma.

Personal History:

  Married

  Farmer by occupation

  Appetite: Normal

  Diet: Mixed

  Bowel movements:Regular

  Micturition: Abnormal

  Alcohol: occasionally.

Family History:

 No member of the family has similar condition.

General Examination:

Vitals: 

Temp: 98°F

Respiratory rate: 28/min

Pulse: 88/min

Blood pressure: 130/70mmHg

Sp O2  98%

GRBS: 138mg%

Systemic Examination:

Cardiovascular Examination:

Thrills: No

Cardiac sounds: S1, S2 positive

Cardiac murmurs: No

Respiratory system:

Position of trachea: Central 

Breath sounds: decreased breath sounds at right IAA and ISA

Abdomen

Shape of abdomen: Distended

Tenderness: No

Palpable mass: No 

Henias orifices: Normal

Free fluid: No

Bruits: No

Liver: Not palpable

Spleen: Not palpable 

Bowel sounds: Yes

Central Nervous system:

Patient is conscious, coherent, cooperatively well oriented to time and place.

Speech: Normal

Sign of Meningitis: No

Provisional Daignosis:

Chronic kidney disease on Maintenance hemodialysis.

Hypertension since 2 years on medication Tab.Stamlo 5mg OD

Diabetes milletus since 3 months on medication Tab.Glimipride 1mg OD

Investigation:

Treatment:

Tab.Nodosis 500mg BD

Tab Lasix 20mg BD

Tab.Nicardia 20mg TID

Cap.Bio D3 once weekly

Tab Shelcal 500mg OD

Tab Orofer XT OD

Tab Ecospirin 75mg H/s