A 78 year old patient with complaints of pedal edema shortness of breath

 

MARCH 8TH 2022

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MARCH 8TH 2022

P R C KARTHIK VARMA

ROLL NO:199

   CASE

A 78 year old patient came with chief complains of

1. shortness of breath since 3 months 

2. pedal edema since 3 months

3.  chest pain- intermittent since 15 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 months back, then he developed exertional dyspnea  associated with cough( wet type-sputum).

there is also H/O bilateral pedal edema which is of pitting type(Grade 1) since 3 months. facial puffiness also seen.

H/O chest pain intermittent since 15 days.

No H/O fever, burning micturition, palpitation, decreased urine output.

PAST HISTORY:

K/C/O HYPERTENSION Since 4 years.

medication: Tab telmisartan 40mg.

Not a K/C/O DM,THYROID,TB,epilepsy.

No history of previous surgery.

 PERSONAL HISTORY:

. Appetite: decreased, due to dyspnea since 2-3 months 

. diet: mixed

. sleep: adequate

. bowel and bladder movements: normal, regular.

. addictions: used to consume alcohol and cigarettes 10 years ago.

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, well oriented to time, place, person.

Thin built moderately nourished 

Pallor- present 

Icterus- absent

Cyanosis- absent

clubbing- absent 

Lymphadenopathy- absent 

Edema- present 

 

 

VITALS:

Temperature: afebrile 

pulse rate: 76

Respiratory rate:18/min

BP:140/80 mm hg

SYESTEMIC EXAMINATION:

CVS:

S1, S2 sounds heard

No audible murmurs 

Thrills: no 

JVP: Is observed

RESPIRATORY SYSTEM:

BAE+ no added sounds

P/A: soft and tender 

CNS EXAMINATION:

Higher mental functions intact

Cranial nerve examination normal

INVESTIGATIONS:

On 28.02.2022

HEMOGRAM:

Hemoglobin: 5.6 gm/dl

Total Count: 10,800 cells/cumm

Neutrophils: 73%

Lymphocytes: 13%

Eosinophils: 8%

Monocytes: 6%

Basophils: 0%

PCV: 18.0 vol %

MCV: 91.4 fl

MCH: 28.4 pg

MCHC: 31.1%

RDW-CV: 19.3%

RDW-SD: 63.2 fl

RBC Count: 1.97 millions/cumm

Platelet Count: 2.44 lakhs/cumm

SMEAR:

RBC: Normocytic normochromic with microcytes, hypochromic target cells, pencil form schistocytes

WBC: Absolute eosinophilia

Platelets: Adequate

Hemoparasites: No hemoparasites seen 

Impression: Normocytic normochromic blood picture, anemia with absolute eosinophilia

LIVER FUNCTION TESTS:

Total Bilirubin: 0.56 mg/dl

Direct Bilirubin: 0.20 mg/dl

SGOT: 13 IU/L

SGPT: 24 IU/L

Alkaline Phosphatase: 373 IU/L

Total Proteins: 5.1 gm/dl

Albumin: 3.0 gm/dl

A/G Ratio: 1.39

RENAL FUNCTION TESTS:

SERUM ELECTROLYTES:

Sodium: 143 mEq/L

Potassium: 4.7 mEq/L

Chloride: 106 mEq/L

Serum Creatinine: 7.6 mg/dl

Blood Urea: 129 mg/dl

ECG:  

 

 

2-D ECHO:

USG:

On 04.03.2022

COMPLETE URINE EXAMINATION:

Colour: Pale yellow

Appearance: Clear

Reaction: Acidic

Specific Gravity: 1.010

Albumin: ++

Sugar: Nil

Bile Salts: Nil

Bile Pigments: Nil

Pus Cells: 4-6

Epithelial Cells: 2-4

Red Blood Cells: Nil

Crystals: Nil

Casts: Nil

Amorphous Deposits: Absent

Others: Nil

  

MARCH 9th 2022

COMPLTE BLOOD PICTURE:

COMPLETE URINE EXAMINATION:

Renal function test:

PROVISIONAL DIAGNOSIS: 

HEART FAILURE WITH PROLONGED EJECTION FRACTION DIAGNOSED AS  CHRONIC RENAL FAILURE ASSOCIATED WITH HYPERTENSION

MANAGEMENT:

1. FLUID RESTRICTION < 1.5 LT/DAY

2. SALT RESTRICTION < 2 GM /DAY

3. TAB. LASIX 40 MG / BD

4. TAB. NICARDIA 10 MG / BD

5. TAB. NODOSIS 500 MG / BD

6. TAB. SHELCAL 500 MG / OD

7. CAP. BIO D3 0.25 MG / OD

8. TAB. OROFER XT / BD

9. INJ. IRON SUCROSE 100 MG IN 100 ML NS / IV OVER 1 HR

10. INJ. ERYTHROPOIETIN 4000 U/ SC X ONCE WEEKLY

11. TAB. MET XL 12.5 MG / OD