67 year old male with pedal edema
67 year old male with pedal edema
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67 year old male came to the OPD on 24/03/2022 with chief complaints of.
Pedal edema since 6 months
Low back pain since 2 months.
HISTORY OF PRESENT ILLNESS
patient was apparently asymptomatic 2 years back then he developed shortness of breath on exertion associated with dry cough for which he wrnt to hospital, given medication.He used to take medication ( (inhalers).He had bilateraledemasince 6 months which was insidious in onset and gradually progressive. It is pitting time.patient also complanied of shortness of breath which was of NYHA grade 2 2months ago which was progressed to grade 3 associated with PND. Patient complain of low back ache since 2 months which was insidious in onset gradually progressive .There is no radiation of pain . Pain is not relieved on medication.
Since one week pain was aggravated and patient was unable to sit or stand.
PAST HISTORY:
Known case of COPD since 2 years and in on inhalers.
Not a known case of diabetes hypertension asthama epilepsy tuberculosis.
PERSONAL HISTORY.
DIET : Mixed
APPETITE: normal
SLEEP : adequate
BOWEL AND BLADDER MOVEMENTS : regular
ADDICTIONS : smoked beedis for about 26 years and stopped 14 years back. Takes alcohol occasionally.
FAMILY HISTORY : not significant
GENERAL EXAMINATION.
Patient is conscious cooperative
Pallor.: absent
Icterus.: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy; absent
Pedal edema: bilateral pitting type.
VITALS.
TEMPERATURE :101F
BP.:120/80mmhg
PR.:110bpm
RR.:28/min
SPO2.:88%at room air 99%@ 5litres of 02
GRBS: 133mg/dl.
Day 2
BP.:120/80mmhg
PR.:88bpm
RR.:22/min
SPO2.:98% with 02
GRBS: 150mg/dl.
DAY 3
BP.:110/70mmhg
PR.:86bpm
RR.:18/min
SPO2.: 98% with o2
GRBS: 109mg/dl.
1.NEBULISATION WITH SALBUTAMOL IPRAVENT AND BUDECORT-6th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
DAY 4
BP.:120/80mmhg
PR.:110bpm
RR.:22/min
SPO2.:99% at room air
GRBS: 100mg/dl.
1.NEBULISATION WITH SALBUTAMOL IPRAVENT AND BUDECORT-6th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- present.
Vocal fremitus- normal on both sides
Measurements:
Anteroposterior diameter- 21cm
Transverse diameter-30cm
Ratio: AP/T- 0.7
Chest expansion: 2.5 cm
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapula
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Vesicular breath sounds
Rhonchi heard.
Decreased breath sounds.
Cardiovascular system:
JVP- raised.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
Abdominal examination:
Abdomen distended, umbilicus- inverted
Soft, tenderness present
No organomegaly.
Central nervous system:
No focal neurological deficit.
INVESTIGATIONS.
ABG.
PH.:7.4
PCO2..43.3
PO2 :97.4
SO2 .95
HCO3: 26.7
Blood group- A Positive
RBS-132mg/dl.
BLOOD UREA' 50mg/dl.
HEMOGRAM.
Hb.
TLC.
N/L/E/M- 92/3/2/3
PCV- 36.2
MCV- 75 .9
MCH- 23.1.
MCHC-30.4
RDW-17.4.
PLT: 2.30
Phosphorous- 3 .6 mg/dl
Serum ca- 9.2mg/dl
Serum creatinine_0.9
LFT.
SGOT.(AST)-41
SGPT (ALT)-38
ALP.-250
TP.-5.4
ALBUMIN-2.98
A/G-1.23
SERUM ELECTROLYTES.
Na_141
K 4.3
Cl.97
Serology- negative.
Troponin1- negative.
ECG.
,
DIAGNOSIS: COPD WITH RIGHT HEART FAILURE.
TREATMENT-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING.
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD.
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