A 67 year old male with complaints of

 A 67 year old male resident of Narketpally, who works at tea stall came to the OPD with complaints of

- shortness of breath since 1 week 

- pedal edema since 1 day

Patient was having shortness of breath since 1 week and he was not able to sleep in supine position due to SOB 

SoB was insidious in onset ,gradually progressive 

It increases on supine position

Orthopnea and Paroxysmal nocturnal dyspnea are present

Bilateral Pedal edema since 1 day 

History of previous treatment for Tuberculosis:  Antitubercular therapy for  9  months as he was diagnosed with tuberculosis 18years back.

No history of Diabetes , Hypertension,CAD,CVA, Epilepsy.

No known allergies to drugs and environment

Family history: insignificant

Personal history: 

Diet -mixed

*  Decreased appetite since 7days

*  Decreased sleep since 7days

Regular bowel and bladder

** Addictions:

Alcohol since 18 years and consumes 3-4times per week about 180-360ml

Smoking since 18years and smokes 1 pack per day. 

General examination:

Patient was conscious, coherent, cooperative and examined in sitting posture in a well lit room.

Pallor -

Icterus -

Cyanosis -

Clubbing- 

Bilateral Pedal edema ( pitting type )

Vitals:

Temp : afebrile 

Pulse: 80bpm

RR: 18cycles /min 







  

  Inspection:
Trachea is central in location                        -Apex beat is not seen.                                  
-Shape of chest  is Normal                            
-Chest movements are normal on both sides 
-There are no scars, sinuses, visible pulsations or dilated veins over the chest.
 
Palpation :
Trachea: Central in position
Apical Impulse - felt 5th Intercostal Space  medial to mid clavicular line which was diffuse.
Chest Movements :decreased chest expansion in left supraclavicular area
Vocal Fremitus : decreased at Left supraclavicular area

Percussion:
Resonant on all lung areas
Liver Span : 7 inches
Liver Dullness felt at 6th intercostal space

Auscultation:  
Bilateral air entry present
Vocal Resonance : decreased at Left supraclavicular area
Added Sounds Wheeze Heard
Basal crepitations are left apex lobe area
CVS examination:
Palpation:
Parasternal heave +
Apex impulse is diffuse in 5th intercostal space
 S1,S2 are heard.
ECG: 6/02/2022
Complete urine examination
Serum electrolytes:
Serum creatinine:
Blood urea:


Liver function test:


Hemogram:
Echo :


Chest x-ray:




Treatment:

Inj . LASIX 40mg/i.v/bd 

Fluid restriction <1.5 litres 

Salt restriction<2g /day 

Inj. Augumentin 1.2mg/iv /bd 

Inj. Pantop 40mg/iv /od 

Inj.Thiamine 100mg /iv/od 

Neb. Duolin ,budecort tid











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