67 YEAR OLD MALE WITH PEDAL EDEMA

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 67 year old male came with a cheif complaint 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.