A 65 yr old male patient with swelling on the both the legs and difficulty in breathing ( short case)

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Chief complaint

65years old male resident of nagarjuna sagar came to opd with chief complaint of bilateral pedal edema and SOB

History of Present Illness:

-Patient was apparently asymptomatic 10years back, then he met with an accident following which he started using NSAIDS following which he developed heart failure. 

-H/o 1 episode of tonic seizures at night 5years back (phenytoin 100mg/BD ) bilateral pedal edema since 4years , pitting type, aggrevated on standing and relieved on lying down

-SOB since 1week insidious onset, gradually progressive from grade 2 to grade 3 sometimes grade 4

-Facial puffiness 

-Decreased urinary output

-orthopnea present

-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

-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

   

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: Afibrile

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:

Position of trachea: central

Breath sounds: vesicular

Chest is bilaterally symmetrical

Movements with respiration are equal on both sides

Bilateral air entry present

Dull sound on percussion

Crepts in auscultation

Abdomen

Inspection

Shape of abdomen: Distended

Flanks full

Umbilicus central

Sinuses,scars -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

Central Nervous system:

 Pt is conscious

Speech:normal

Neck stiffness:no

Cranial nerves:normal

Motor and sensory system:normal 

PROVISIONAL DIAGNOSIS :- 

CKD with hypertension

Investigation:

Treatment:

01 .Tab. Lasix 40mg po/bd ( to reduce preload) 

02 .Tab. Nodosis 500mg po/bd( acidbase balance) 

03 .Tab. Orofer po/od ( anemia) 

04 . Tab .shelcal po/od ( dietary supplement) 

05. Tab . Phenytoin 100mg po/od                  ( epilepsy) 

06 .Tab .metxl 25mg po/od ( metoprelol for hypertension) 

07. Tab . Isolazine po/od ( Heart failure) 

08. Cap . Bio D3 po/once weekly ( vit D 3 because ionized calcium is low)