final long case

70 years old male come with a complaints of bilateral pedal edema since 1 month  decreased urine output and SOB since 25 says    

This is an online e-log book to discuss our imppatient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Date of admission -24/12/22
 
Cheif complaint

70 years old male come to OPD with a complaints of bilateral pedal edema since 1 month
Decreased urine output since 25 days
SOB since 25 days

History of present illness

Patient was apparently asymptomatic 1 month back than he developed bilateral pedal edema from 1month  up to knee joint pitting type
Decreased urine output since 25 days 
Associated with SOB grade 2 initially it was grade 1 progresing into grade 2
Associated with loss of appetite and nausea
No h/o loose stools 
No h/o fever
No h/o burning micturation


Past history

N/k/c/o hypertension ,DM , asthma ,CAD , epilepsy


Personal history

Diet -mixed
Appetite - decreased
Bowel and bladder -regular
Micturation -normal
No drug allergies
Habits - alcohol occasionally
Tobacco chewing 40 years

Family history

No significant family history

General examination

Patient was conscious and coherent cooperative well oriented to time and place 
No pallor
No icterus
No clubbing
No lymphadenopathy
No dehydration
No malnutrition 
Pedal edema - bilateral pedal edema
Vitals
Temparature -afebrile
RR-32cpm
Pulse rate -80bpm
BP-132/80 mm hg 

Systemic examination

CVS
Inspection
Chest wall - symmetrical
No precardial bulge
No dilated veins
No scars 

Palpation 
Apical impulse -present 2cms lateral to the midclavicular line
No dilated veins
Parasternal heave -present 

Percussion
Dullness heard at 5 intercostal space on both sides
Ascultation
S1s2 heard 

Respiratory system
Inspection
Chest -symmetrical
Shape -funnel shape 
Trachea-central
No scars
No dilated veins 
Palpation
Chest movements- symmetrical 
Trachea-central 
Percussion
Dullness on percussion 
Auscultation 
Breath sounds- vesicular


GIT
Shape of the abdomen -scaphoid
No tenderness
No palpable mass
Hernial orifice -normal
No free fluid
No bruits
Liver not palpable
Spleen not palpable

CNS
Conscious
No neck stiffness
Memory intact 
Provisional diagnosis
Heart failure 

Investigation

Final diagnosis-CKD with heart failur and pleural effusion 

Treatment
Inj lasix 40 mg iv /bd
Inj piptaz 2.25 g iv/tid
Tab nodosis 500 mg po/bd
Tab orofer po/od


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