78 yr old male with sob,pedal edema, generalised weakness

78 year old male with farmer by occupation, resident of Annaram came with chief complaints of SOB on exertion, pedal edema and generalised weakness since 20 days

HOPI:

Pt was apparently asymptomatic 3 months back, then developed SOB which gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations. 

Orthopnea (+)ve, PND (+)

Not h/o facial puffiness, no decreased urine output, no burning micturition

H/o fever on and off since 2 months

PAST HISTORY:

Pt was diagnosed with dengue 1 month prior

K/c/o DM since 10 years, on T. Zoryl-m2 po/bd

K/C/O serizure disorder, on T. Carbamazepine 200mg po/od

Not k/c/o HTN, CAD, asthma, CVA, TB

No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena

PERSONAL HISTORY:

Sleep adequate, appetite decreased, bowel movements irregular, bladder regular, occasional alcoholic, non smoker

GENERAL EXAMINATION:

O/e- pt is conscious, coherent, cooperative with respect to place ,time and person

AFEBRILE

BP- 150/80mmgHg

PR- 81 BPM

RR-24cpm

SPO2- 99% 

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

JVP(-)

SYSTEMIC EXAMINATION:

CVS- S1, S2 heard, no murmurs, 

apex in 6th ICS, MCL, no thrills

RS- BAE(+VE), NVBS

P/A- abdomen distended, umbilicus everted, no fluid thrill, soft, Bowel sounds(+)

INVESTIGATIONS:

Xray:

ECG:

2D ECHO:

USG:

Input and output:

Fever chart:

Review of USG:

PROVISIONAL DIAGNOSIS:

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

TREATMENT: 

Fluid restriction < 1.5L/day

Salt restriction < 2.4g/day

TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)

TAB ZORY - M2 PO/BD

TAB ECOSPRIRIN - AV (70/20) PO/HS

TAB CARBAMAZEPINE 200mg PO/OD

BP-MONITORING 4th HRly

GRBS 6th HRly

                  8am-2pm-8pm

I/O CHARTING

TEMP CHARTING