A 65 yr old Male with Pedal Edema and SOB


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. 


05/08/2022


Blog by

 Aruna.J
Roll no 61



A 66 year old male who is a resident of Suryapet and a businessman by occupation came to opd four days back with chief complaints of 

1. Pedal Edema since 3 months 

2. Shortness of breath since 3 months 



HOPI 

Patient was apparently asymptomatic 12 years back . 

He was having complaints of vomitings and chest pain and was diagnosed with Ischaemic Heart disease and went through bypass surgery (CABG) . 

The same time he was diagnosed with DM and Hypertension. 


3 months back was having pedal Edema which is pitting type and extends till knees . shortness of breath on walking a long distance for which he went to hospital and was diagnosed with kidney disease. 

He came here 4 days back for dialysis. He had 2 rounds of dialysis till now . 


PAST HISTORY- 

A known case of Diabetes Mellitus and Hypertension since 12 years .

No history of Tb , Epilepsy , Asthma , Thyroid abnormalities. 

He has history of CAD 


SURGICAL HISTORY- went through CABG 12 years back . 

FAMILY HISTORY- no significant family history 

DRUG HISTORY- he has no drug allergy and is on medication for DM and HTN .


PERSONAL HISTORY- 

Diet - stopped eating non veg since 3 months

Appetite- normal .

Sleep- not adequate. 

B&B- burning micturition and increased frequency. 
Bowel movememts - irregular (constipated)

Addictions- none .


GENERAL EXAMINATION- 

Patient is conscious, coherent and cooperative 

Moderately built and nourished 

Pallor- Present
Icterus- absent 
Cyanosis- absent 
Clubbing- absent 
Lymphadenopathy- absent 

Edema - Pedal Edema present  Pitting type .
VITALS - 

Temperature- Afebrile 
PR - 65bpm 
RR - 16 cpm
BP - 130/70mm of hg 


SYSTEMIC EXAMINATION-.
CVS-
Inspection- vertical scar seen on the chest(previous CABG surgery)
JVP - not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent


Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.

Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS, 
Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS


Abdomen examination:

INSPECTION
Shape : normal 
Scar : due to burn Present around the umbilicus. 

Umbilicus:normal 
Movements :normal
Visible pulsations :absent

Skin or surface of the abdomen : normal 

PALPATION -No Tenderness , no Orgamomegaly . 

PERCUSSION- tympanic

AUSCULTATION :  Bowel sounds heard


CNS : 
Higher mental functions intact .
No focal neurological deficit’s present .



PROVISIONAL DIAGNOSIS- 

Chronic Renal Failure associated with diabetes and hypertension since 12 years . 




INVESTIGATIONS- 

CBP-
CUE-
ECG-

RFT-
2D Echo-
USG-


Treatment-
Tab.DYTOR 20mg PO/OD(morning).
Tab.AMLONG 5mg PO /OD- (morning).
Tab.Nicorandil 5mgPO/OD (afternoon).
Tab.PB GENIX  PO/OD (afternoon).
Tab.Clinidipine10mg +Metoprolol 50mg PO/OD.
Tab.Atorvas 10mg PO/OD.
Tab.BIO-D3 PLUS PO/OD.
Inj. HAI TID based on GRBS.












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