A 55 year old male patient with B/L pedal edema
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A 55yr old male patient,daily wage labourer by occupation came resident of mothkoor
C/o Pedal edema since 20 days
Facial puffiness since 20 days
Sob(grade-3) since 20 days
Loss of appetite since 20 days
Decreased urine output since 10 days
A 55yr old male patient was apparently asymptomatic 1 yr back, when he developed weakness of left upper and lower limbs for which he went to the hospital and was diagnosed to have HTN. (Medications prescribed but never taken )
History of Pedal edema since 20 days - Insidious in onset, gradually progressive from involving ankle to above knee , b/l pitting type.
History of palpitations.
History of Facial puffiness since 20 days
History of Sob(grade-3) since 20 days- insidious in onset,aggregated while talking and walking to washroom
PERSONAL HISTORY
he is been married for 32 years
He is a case of infertility
Diet is mixed
Loss of appetite since 20 days
Decreased urine output since 10 days
Occasional alcohol consumer
Occasional tobacco abuser
No NSAID abuse
No burning micturition
No cough
No chest pain
No orthopnea
No PND
PAST HISTORY
HTN since 1 yr(medications prescribed- but didn't use.)
Non diabetic
No h/o TB, Asthma, epilepsy
GENERAL EXAMINATION
Patient is conscious coherent cooperative comfortable moderately built and moderately nourished
O/E:
Temp- afebrile to touch
pallor- present
No- icterus, cyanosis, lymphadenopathy
B/l-Painless soft pitting pedal edema present
B\L pitting edema
Vital signs
Temp-96.4F
BP-160/80mmhg
Pr-89/min
Spo2-96% on RA
Rr-23/min Regular
SYSTEMIC EXAMINATION
Examination of oral cavity-Normal
Abdomen inspection
Shape-locally distended
Flanks – full
Umbilicus -Position?, slit shaped
Skint-normal
Palpation
Superficial palpation-abdomen is soft ,warm
Percussion
Fluid thrill/Shifting dullness/ Puddle’s sign-Present
Percussion of liver span
Auscultation
Bowel sounds – 10 to 15 per minute for small bowel
3 to 5/minute for large bowl
CVS EXAMINATION
Cvs-S1S2 heard
RS- BAE+, NVBS, no added sounds
P/A: distended, soft, non tender
CNS EXAMINATION -NAD
Treatment given
1.Fluid restriction for less than 1.1 L/day
2.Salt restriction less than 2.4 g/day
3.Tab lasix 40 MG/pO/BD
4.Tab NODOSIS 500 MG PO/BD
5.Tab OROFER- Xt po/od
6.Tab SHELCAL PO/OD
7.Tab. NICARDIA 10 MG/po/bD
8. Monitor vitals inform SOS
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