55 Yr old Man with shortness of breath
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A 55 Yr old man presented with shortness of breath since 20 days and swelling of both lower limbs ( upto knees ) since 10 days
History of presenting illness :
Patient was apparently asymptomatic 20 days back . Then he developed Shortness of breath , which increase on lying down , walking and relieved to some extent in sitting .
Complaint of pedal Edema since 10 days gradually progressed till knees
History of facial puffiness 1 week back and it is resolved .
History of non progressive , non radiating Lower backache from past 5 years , for which he used analgesics from past 3 years every 2-3 days .
No history of chest pain , palpitations , sweating
No history of fever , cold , cough
No history of burning Micturition , frothy urine , Hema turia
No history of decreased urine output
History of past illness :
Not a known case of Diabetes Mellitus , Hypertension , Asthma , TB , CAD , CVA , Epilepsy
Underwent surgeries for hernia right side 8 years back and hernia left side 4 years back .
Personal History :
Patient takes mixed diet , appetite is good , bowel and bladder movements are regular , sleep is disturbed .
He’s allergic to fish , brinjal .
He consumes 90 mL whiskey daily from past 20 years
Daily routine :
Patient wakes up around 6 in the morning and goes out around 7 and has his breakfast around 10 am , continues to work and around 2 am he comes home and sleep for an hour or 2 and resumes his work in vegetable Market till 9 pm . Later he drinks 90 mL whiskey and comes home , have dinner and sleep around 10 pm .
Family history :
His mother and elder brother had similar complaints of Shortness of breath .
Treatment history :
Patient used NSAIDS for back pain every 2-3 days for past 3 years .
GENERAL EXAMINATION
Patient is examined in well lit area After taking consent
Patient is conscious , coherent , cooperative , well oriented to time , place , person .
Patient is moderately built and moderately nourished .
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - present
Pedal edema - Grade ll ( Till knees )
VITALS :
Temp - Afebrile
BP - 130/70 mm Hg
PR - 66 bpm
RR - 18cpm
GRBS - 92 mg/dL
Elevated JVP
CVS EXAMINATION :
INSPECTION
chest normal in shape
no visible pulsations
no scars
no dilated veins
PALPATION
No thrills , heaves
AUSCULTATION
Done in all 4 areas . S1 S2 heard . No murmurs heard
Apex beat - 5th ICS , 2 cms lateral to Mid clavicular line
RESPIRATORY SYSYTEM-
INSPECTION-
trachea appears central
chest wall normal
no scars
no sinuses
no dilated veins
PALPATION
trachea central
symmetrical expansion of chest seen
Tactile vocal fremitus -decreased on right mammary and axillary area
PERCUSSION
dullness felt at axillary area on right side
AUSCULTATION
normal vesicular breath sounds heard and diminished sounds at right mammary and axillary areas,
CNS - no focal neurological deficits elicited
PER ABDOMEN - soft , non tender , no hepatomegaly , spleen not palpable
PROVISIONAL DIAGNOSIS
Heart failure with reduced ejection fraction , with pleural effusion , ckd under evaluation
Treatment-
1.inj lasix 40 mg iv bd
2.fluid restriction <1lt/day and salt restriction <2gm/day.
3.tab.ecosprin po
4. Tab MET-XL 12.5 mg po
5. Inj. Thiamine 200mg direct iv bd
6. Pantop 40 mg po bd
7. Bp charting every 4th hrly and grbs 12th hrly
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