A 65years old male came to opd with chief complaint of bilateral pedal edema and Shortness of breath
A 65 yr old male patient with swelling on the both the legs and difficulty in breathing ( short case)
January 20,2023
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CHIEF COMPLAIN:
A 65years old male resident of nagarjuna sagar came to opd with chief complaint of bilateral pedal edema and Shortness of breath
History of Present Illness:
-Patient was apparently asymptomatic 10years back, then he met with an accident fell while riding bullock cart injuring his mandible) .
Then he started using NSAIDS following
8 years back developed heart failure
6 years back he was diagnosed with increased blood pressure, kidney disease
5 years back 1 episode of tonic seizures at night (phenytoin 100mg/BD )
3 years back - shortnes of breath, Abdominal distention, decreased urine output then he was taken to hospital in Hyderabad
He was diagnosed with Nsaid induced
Patient has bilateral pedal edema , pitting type, aggrevated on standing and relieved on lying down
-since one week SOB insidious onset, gradually progressive from grade 2 to grade 3 sometimes grade 4
-Facial puffiness
-Decreased urinary output
-no h/o fever
-no h/o cough,cold
-no h/o burning micturition
History of Past illness:
-h/o CKD since 5years(12 sessions of hemodialysis is done)
-h/o hypertension since 4years
Tab -met XL 25 mg od
-no h/o Diabetes, asthma,TB
Personal History:
Diet - Mixed
Appetite - decreased since 5years
Micturition-normal
Bowel and bladder movements- Regular
Sleep- disturbed
Addictions - Patient consumes alcohol regularly since 40 years stopped since 1year
smokes cigarette 10-12/day since 40 years
Daily routine before sob development: patient is a farmer by occupation and gets up morning early and goes to farm to do his work has lunch at 1pm and stays at farm till evening (sunset) has mixed diet everytime goes to bed at 10 pm ( mostly)
Family History:
No significant family history
General Examination:
Patient was examined after taking his consent.
Patient was conscious, coherent, cooperative and well oriented to time place and person
Patient was well nourished and well built.
Pallor- Absent
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphadenopathy - absent
Vitals:
Temp: Afebrile
Respiratory rate:20cycles/min
Pulse:114bpm
Blood pressure:150/80mmhg
Systemic Examination:
Cardiovascular Examination:
Thrills:no
Cardiac sounds:S1,S2 heards
Cardiac murmurs:no
Respiratory system:
Inspection:
Position of trachea: central
Breath sounds: vesicular
Chest is bilaterally symmetrical
Movements with respiration are equal on both sides
Bilateral air entry present
Chest : symmetrical
Trachea position - central
No drooling of shoulders
Movement with respiration is symmetrical on both sides
Palpation
Treachea position - central
Auscultation
Vesicular breath sounds
Percussion
Right lower side has a dull note
Abdomen -not present
No dilated veins
Palpation
Tenderness:no
Palpable mass:no
Free fluid:yes
Bruits:no
Liver:not palpable
Spleen:not palpable
Auscultation
Bowel sounds:yes
Oral cavity examination:
Teeth Mobility : present
Generalized calculus
No evidence of gingival hypertrophy
PROVISIONAL DIAGNOSIS
CKD
Hypertension
Heartfailure
Pleural effusion
INVESTIGATION: