A 70 year old male with Shortness of breath and Pedal edema

A 70 yr old male who is a resident of  nalgonda, came to OPD with chief complaints of Shortness of breath since 1 month and pedal edema since 20 days.

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 

1 month ago, then the patient complained of Shortness of breath (grade 3) later 20 days back he developed pedal edema so he was taken to a nearby private hospital and over there he was investigated and his hemoglobin was found to be 3.9gm% so he was given 2 PRBC units and was discharged.

He didn't feel better after that so he thought of getting treated in our hospital and got admitted over here. 

He felt SOB even while he was talking since 1 month, but it decreased after he was treated over here.

He has a history of shortness of breath when he suffered from any kind of fever in his past, but that used to decrease the moment when the fever got subcided.

His pedal edema extended from waist to feet, but after some medications given over here, that reduced and was confined only below knee.

PAST HISTORY -

Pt is not a known case of HTN, TB, DM and CAD, asthma, epilepsy.

PERSONAL HISTORY -

Appetite:normal

Diet:mixed

Bowel and bladder:regular

Sleep: adequate 

Addictions - He's a chronic alcoholic and daily drinks 90ml since the past 40yrs

He's also a chronic smoker and smokes one pack of beedi or cigarettes daily, since the past 40 years.

FAMILY HISTORY - 

not significant 

GENERAL EXAMINATION -

Patient is conscious coherent cooperative and well oreinted to time and space.

BP: 100/70mmhg

PR:80

RR: 20 cpm

Temp: afebrile 

Pallor seen 

Edema seen

No icterus, cyanosis, clubbing, and lymphadenopathy 

SYSTEMIC EXAMINATION - 

CVS:S1 S2+, pansystolic murmur heard

RS: BAE+, right infrascapular crepts and rt. Infrascapular wheeze heard. 

CNS: no focal neurological deficits.

P/A:soft,non tender

INVESTIGATIONS-

On 9 sept 22 -

On 11 sept 22 -

 

On 12 sep 22 -

On 13 sep 22 -

TREATMENT -

1. Inj Lasix 20mg IV BD

2. Inj Optineurin IN 100ml NS IV

3. T. Ecosprin AV Po OD

4. Nebulization with Budecort