70 years old male come with a complaints of bilateral pedal edema ,SOB and decreased urine output

[ LONG   CASE ]

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DATE OF ADDMISSION:- 17/01/2023

CHEIF COMPLAINTS:-

A 70year Old Male , farmer by occupation presented to OPD with chief complaints of bilateral pedal edema since 1 month , shortness of breath since 1 month and decreased urine output since 1 month .

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 1 month back than he noticed bilateral pedal edema ,pitting type upto knee joint  since one month.Pedal edema is subsided on medication .Decreased urine output since 25 days 

SOB grade 2 initially it was grade 1 progresing into grade 2. Associated with loss of appetite and nausea

Not associated with loose stools,fever.

 

HISTORY OF PAST ILLNESS:-

 Patient was admitted on 24/12/2022 and he was on hemodialysis and during the course of time he developed type 1 ,2 respiratory failure and refractory pleural effusion. Patient was intubated and hemodialysis is done. On therapeutic pleural tap -transudate effusion. Patient was removed from ventilator and extubated.

Not known a case of asthma, TB, CAD, epilepsy.

Known case of HTN since 2 months .

PERSONAL HISTORY:-

Married

Diet - mixed 

Appetite :- lost 

Bowel  movements-Regular        

Micturition:- abnormal 

Sleep :- Adequate 

Addictions:-

           Alcohol - occasional

           Tobacco smoking - since 40 years

Farmer by occupation.

FAMILY HISTORY:-

 No significant family history .

GENERAL EXAMINATION:-

Patient is conscious, coherent, co-operative and well oriented to time and place .

Moderately built and nourished.

There are no signs of icterus ,cyanosis ,clubbing lymphadenopathy, pedal edema.

Pallor is present 

VITALS:-

Temperature- Afebrile 

Pulse rate- 103 bpm

Respiratory rate - 22cycles/min

BP- 140/90mm of hg

Spo2- 99%

GRBS -163mg/dl

SYSTEMIC EXAMINATION:-

•CARDIOVASCULAR SYSTEM

Inspection:-

Bilaterally symmetrical chest

No visible engorged veins,scars or sinuses on chest.

Palpation:-

S1 S2 are heard

No thrills , no murmurs 

Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation:-

Cardiac rate - 100 beats per minute 

No cardiac murmurs heard

•RESPIRATORY SYSTEM:-

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- crepts

 Inspection:-

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear to be decreased on right side and it's Abdominothoracic type. 

Apex beat is localised at 5th intercostal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 

No rib crowding ,no accessory muscle usage, no drooping of shoulder.

Palpation :-

All inspectory findings are confirmed

Trachea is in central position 

Apical impulse -present 2cms lateral to the midclavicular line

No dilated veins

Chest movements-asymmetric 

Percussion:-

Dullness in 5th intercoastal area

                                     Right.                     Left 

Supraclavicular.      Resonant.              Resonant 

Infraclavicular.             R                             R

Mammary                    R                              R

Axilllary.                        R                             R

Infraxillary                 dull                             R

Suprascapular.             R                           R

Interscapular.               R                             R

Infrascapular                R                             R

Auscultation:-

                                   Right.                 Left

Supraclavicular :-    NVBS.            NVBS

Infraclavicular:-       NVBS.             NVBS

Mammary. :-             NVBS.             NVBS

Axillary:-.                   NVBS.             NVBS

Infra axillary:-           Crepts          Crepts       

Supra scapular:-      NVBS            NVBS

Interscapular:-.        NVBS.             NVBS

GIT

Inspection 

Shape of the abdomen -scaphoid

Flanks- full

Umbilicus - central and inverted 

Sinuses and scars - not visible

No dilated veins

Palpation 

No local rise in temperature

No tenderness

No palpable mass

No organomegaly

Hernial orifice -normal

Free fluid - yes

No bruits

Liver not palpable

Spleen not palpable

Percussion:-

Shifting dullness positive

Auscultation:-

Bowel sounds heard

•CENTRAL NERVOUS SYSTEM 

Patient is conscious , coherent, cooperative and we'll oriented to time and place.

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- normal

Memory intact

INVESTIGATIONS:-

 18-01-2023

HEMOGRAM 

ABG

LFT

RFT

2D ECHO

19-01-2023

17-01-2023

18-01-2023

19-01-2023

PROVISIONAL DIAGNOSIS:-

CKD on MHD.with right heart failure and pleural effusion 

TREATMENT:

Tab lasix 40mg PO/BD

Tab cefixime 200mg PO/BD

Inj optineuron 1amp IV OD

Tab nodosis 500mg PO TID

Tab shelcal 500mgPO OD

Tab orofer XT PO OD

Neb duolin+mucomir 8th hourly

Neb budecort 8th hourly

Tab spironolactone 25mg PO OD