55 year old male with SOB

 GENERAL MEDICINE 

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .

55 YEAR OLD MALE PATIENT WITH SHORTNESS OF BREATH AND PEDAL EDEMA

Case details:

55 year old male,driver by occupation, came to the OPD with the chief complaints of Shortness of breath and pedal edema since 4 days, low grade fever and dry cough since 2 days.

History of presenting illness - 

Patient was apparently asymptomatic 1month ago, then he developed 

1)shortness of breath which is incidious, gradually progressive, NYHA grade 2, aggravated on exertion and relieved with rest.

2)Bilateral pitting type of pedal edema extending upto ankles,aggravated on walking, relieved on lying down.

History of decreased urine output. 

Then he went to local hospital and diagnosed as ckd.

5 sessions of dialysis done 

Last session - 20 days back and discharged

He came to KIMS, Narketpally on 08/03/2022 with c/o sob and pedal edema since 4 days and low grade fever and dry cough since 2days

No history of chest pain/palpitations.

No history of chronic cough/hemoptysis.

Past history:

He is a known case of T2 DM since 3yrs and hypertension since 6 months and on medication.

Not a known case of epilepsy,asthma,

TB,CAD,CVA.

NO history of previous surgeries

Personal history:

Diet-mixed 

Appetite-normal

Bowel and bladder movements-regular

Habits- 90ml of alcohol daily since 20yrs,

            - chewing gutka since 20 yrs.

             - chr.smoker since 20yrs daily 2-4 beedis.

General examination:

Patient is conscious, coherent, cooperative, moderately built and nourished.

Pallor +

No signs of, icterus,cyanosis,clubbing,

lymphadenopathy.

Bilateral pitting type of edema present extending upto the level of ankles. (depression of 2 mm noted,rebounding immediately).

Vitals:

Temp: afebrile

PR-80bpm

RR-18cpm

BP-120/70 mm Hg

SpO2-98% @ RA

Systemic examination:

CVS-S1,S2 heard,no murmurs. 

RS-BAE present, clear.

CNS-NAD

P/A-soft,non-tender,bowel sounds+

INVESTIGATIONS:

Provisional diagnosis:

HEART FAILURE WITH REDUCED EJECTION FRACTION DIAGNOSED AS CHRONIC KIDNEY DISEASE.

Treatment:

1.fluid restrictions <1.5L/day.

2.salt restrictions <2g/day

3.TAB.LASIX 40mg BD

4.TAB.ECOSPORIN -AV OD

5.TAB.MET-XL 12.5mg OD

6.TAB.NODOSIS 500MG BD

7.TAB.SHELCAL 500MG OD

8.TAB. BIO-D3 0.25MG OD

9.TAB.OROFER-XT OD

10.inj. HAI sc Acc.to Grbs Tid

11.inj ERYTHROPOIETIN 4000U SC x ONCE WEEKLY