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

Comments

Post a Comment

Popular posts from this blog

70/M WITH FEVER SINCE 4DAYS AND DRY COUGH SINCE 4DAYS

Image
Unit 3 admission: Interns- Jeeharika Archana Harsha Kalyan Sreeja Dr.Raveen PG1 Dr.vaishnavi PG2 Dr.Vamshi PG3 Dr.Aravind PG3 Dr.Hareen SR Dr.Praveen Naik Ass.Prof 70year old male presently staying at home,r/o pochampally,was apparently alright 8days ago,then patient son met with an accident (sustained multiple fractures). patient is in grief about it and used to visit his son 3days ago,patient had an episode of syncope lasting for 2-3mins .Later he woke up and did his daily routine activity(like cooking ).Patient lives with his wife who is also not well.since next day ,patient was in altered state ,having irrelevant talk ,associated with involuntary passage of urine.H/O pricking movements present. Patient is able to walk on his own till yesterday.No H/O seizures ,ENT bleed ,head trauma ,No h/o weakness . Since morning patient is unable to walk on his own ,associated with stiffness of limbs (b/l UL and LL).patient is in altered state.Not oriented to time,place and person. C/o fever sin
Read more

50 year old female with loss of speech and weakness in left arm and lower limb

Image
50 years old female a diabetic and hypertensive since past 12 years and is on tab Glimipride 2mg and metformin 500 mg twice daily and tablet telmisartan 40mg + cilindipine 10mg + hydrochlorthiazide 6.25 mg once daily presented to our casuality with Complaints of loss of speech since yesterday morning and according to the attenders patient has hearing difficulty also since many years ( they could not recollect the exact time) Patient was apparently asymptomatic till morning . she went to a diagnostic center in the morning to give her fasting blood sample after which she came home, and had a nap after she woke up she was unable to talk, she went to shower after that , attenders have observed she couldn’t drape her saree and had weakness in right upper limb and lower limb with deviation of mouth to left .  She was taken to a near by consultant where her BP was 190/90 mmhg and GRB 370 mg/dL They have given medication for her hypertension , and advised for MRI Brain and was referred to our
Read more