60 year old male with complaints of dyspnea on exertion and pedal edema since 1.5 years



 
60 year man presented with complaints of 
Dyspnea at rest since 15 days
Bilateral pedal edema since 10 days upto knees
Facial puffiness since 1 week

Patient works as a tailor at a local village. He has been consuming Zarda since the last 20years he stopped ten years back and alcohol intake since 20 years stopped in 2003  and resumed in 2011.

He was diagnosed on routine investigations to be a diabetic and was using medication on and off and is a known case of hypertension since 10 years and was on irregular medication and has been using regularly for the past 4 to 5 years. 
He has been experiencing Dyspneic and palpitations since the last 10 years. 
 Patient noticed bilateral pedal edema extending up to ankle pitting type, 2 years back.

For which he paid a visit to our hospital and was told that he had kidney failure and was started on maintainence oral medications.

 He also complains of tingling sensation upto the ankles since 1 year.

Slippage of footwear since 1 year

He one day developed ulcer in his left foot 1 year back, on his left foot between his great toe and second toe for which he took treatment from a local hospital.

Since 15 days, he has been having Dyspnea at rest
Bilateral pedal edema gradually extended upto his knees since 10 days
Facial puffiness since 1 week.
EXAMINATION

Vitals:

Patient is conscious coherent cooperative

No pallor/icterus/cynosis/clubbing/lymphadenopathy

Blood pressure: 140 / 90 mmhg

Pulse rate: 90 BPM

Spo2 96% at Room air 

Cvs - 

JVP raised 

Apex beat in 6th left ICS at the MCL

S1,S2 heard

Respiratory system: 

Bilateral airway entry +

Clear on auscultation 

Abdomen:  soft ,non tender
No organomegaly
Bowel sounds +
Bilateral pedal edema extending upto knee

Central nervous system: normal 
Diagnosis:HFREF WITH EF-46% SECONDARY TO IHD,CKD STAGE 5 WITH TYPE 2DM WITH HTN













TREATMENT
DAY 1:
1. Head and elevation
2. Oxygen supplementation if spo2 less than 90%
3. Fluid restriction less than 1 litre per day
4. Salt restriction less than 2 gram per day
5. Tab lasix 40 MG IV BD
6. Tab ecosprin AV (10/75)PO/HS
7. Tab cardivas 3.125 mg
8. Monitor vitals
9. Tab aldactone 25mg PO/OD

DAY 2:
1. Head and elevation
2. Oxygen supplementation if spo2 less than 90%
3. Fluid restriction less than 1 litre per day
4. Salt restriction less than 2 gram per day
5. Tab lasix 40 MG IV BD
6. Tab ecosprin AV (10/75)PO/HS
7. Tab cardivas 3.125 mg po/OD
8. Monitor vitals
9. Tab aldactone 25mg PO/OD
10. GRBS charting 8th hourly

DAY 3:
1. Head and elevation
2. Oxygen supplementation if spo2 less than 90%
3. Fluid restriction less than 1 litre per day
4. Salt restriction less than 2 gram per day
5. Tab lasix 40 MG IV BD
6. Tab ecosprin AV (10/75)PO/HS
7. Tab cardivas 3.125 mg po/OD
8. Monitor vitals
9. Tab aldactone 25mg PO/OD
10. GRBS charting 8th hourly

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