CASE HISTORY

 24 November, 2021

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A 65 year old male patient presented to the opd with chief complaints of

Pedal edema , shortness of breath, facial puffiness, decreased urine output.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 years back then developed right sided hemiparesis and was diagnosed with CVA 

1 yr back patient was diagnosed with DM and HTN.

Also patient developed pedal edema upto knee level and shortness of breath for which he was diagnosed with chronic kidney disease at nalgonda hospital and was suggested on medication.

Since last 20 days patient developed pedal edema pitting type which gradually progressed towards face , shortness of breath, facial puffiness and decreased urine output.

PAST HISTORY:

No history of surgeries in the past.

Patient is a known case of hypertension since 1 year.

FAMILY HISTORY:

No history of similar complaints in the family.

PERSONAL HISTORY:

Diet - mixed

Appetite- reduced

Sleep- reduced

Bladder movement- decreased

Addiction: Non smoker , Alcoholic

GENERAL EXAMINATION:

Pallor is seen

Edema is seen ,pitting type ( anasarca)

No icterus

No cyanosis

No clubbing

No lymphadenopathy

VITALS:

Temperature- 97.6degree F

BP- 110/70mm of Hg

Respiratory rate- 25 breaths/min

Pulse rate - 90 bpm

SYSTEMIC EXAMINATION:

CVS:

No thrills

No murmurs

S1S2 heard

RESPIRATORY SYSTEM

Dyspnea -+

Wheeze-+

BAE ( Brochial artery embolization)

Breath sounds- Vesicular

ABDOMEN-

Shape of abdomen- Scaphoid

No tenderness

No palpable mass

No brui heard

Spleen not palpable

Liver not palpable

CNS:

Level of consciousness - Conscious

Speech- Normal

No neck stiffness

INVESTIGATIONS:

 

PROVISIONAL DIAGNOSIS:

Acute left ventricular failure

known case of chronic kidney disease and hypertension

TREATMENT:

Salt restriction

Fluid restriction

Inj.Lasix

Inj.Augmenting

Tab.ecosprin

Tab. Met-XL